Provider Demographics
NPI:1376950147
Name:WEATHERS, TANYA
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:WEATHERS
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 1:29 PEMBROOKE CT
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-5012
Mailing Address - Country:US
Mailing Address - Phone:631-553-3276
Mailing Address - Fax:
Practice Address - Street 1:29 PEMBROKE COURT
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-5013
Practice Address - Country:US
Practice Address - Phone:631-553-3276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY685458-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse