Provider Demographics
NPI:1376232942
Name:TAVAKE, AMELIA FATANI
Entity Type:Individual
Prefix:
First Name:AMELIA
Middle Name:FATANI
Last Name:TAVAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40015 SIERRA HWY SUITE B280
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550
Mailing Address - Country:US
Mailing Address - Phone:661-480-6337
Mailing Address - Fax:
Practice Address - Street 1:40015 SIERRA HWY SUITE B280
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550
Practice Address - Country:US
Practice Address - Phone:661-480-6337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-01
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator