Provider Demographics
NPI:1568162899
Name:WALLAN, TAMI LORAINE
Entity Type:Individual
Prefix:MRS
First Name:TAMI
Middle Name:LORAINE
Last Name:WALLAN
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 1:530 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080-3438
Mailing Address - Country:US
Mailing Address - Phone:530-529-1750
Mailing Address - Fax:530-435-6074
Practice Address - Street 1:530 MAIN ST
Practice Address - Street 2:
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080-3438
Practice Address - Country:US
Practice Address - Phone:530-529-1750
Practice Address - Fax:530-435-6074
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT12287152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist