Provider Demographics
NPI:1255844890
Name:WILBURN, TANYA SUE (RN)
Entity Type:Individual
Prefix:MS
First Name:TANYA
Middle Name:SUE
Last Name:WILBURN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 LA MANCHA DR
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-1327
Mailing Address - Country:US
Mailing Address - Phone:608-448-8898
Mailing Address - Fax:
Practice Address - Street 1:3330 LA MANCHA DR
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-1327
Practice Address - Country:US
Practice Address - Phone:608-448-8898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI173010163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse