Provider Demographics
NPI:1275932477
Name:TAVITAS, SUSAN (LICENSED NURSE)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:TAVITAS
Suffix:
Gender:F
Credentials:LICENSED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7440 MARILYN DR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-4226
Mailing Address - Country:US
Mailing Address - Phone:714-488-9091
Mailing Address - Fax:
Practice Address - Street 1:7440 MARILYN DR
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881-4226
Practice Address - Country:US
Practice Address - Phone:714-488-9091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 166898261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health