Provider Demographics
NPI:1174270573
Name:WILLARD, TANYIKA (LVN)
Entity Type:Individual
Prefix:MRS
First Name:TANYIKA
Middle Name:
Last Name:WILLARD
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1432 W 89TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-3416
Mailing Address - Country:US
Mailing Address - Phone:323-696-9534
Mailing Address - Fax:
Practice Address - Street 1:4601 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-2729
Practice Address - Country:US
Practice Address - Phone:213-620-5712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-05
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA201501164X00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse