Provider Demographics
NPI:1598179038
Name:VAN DE WARK, TANIA (RN)
Entity Type:Individual
Prefix:MS
First Name:TANIA
Middle Name:
Last Name:VAN DE WARK
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 1:800 YAUGER WAY SW UNIT F305
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-8923
Mailing Address - Country:US
Mailing Address - Phone:415-269-9665
Mailing Address - Fax:
Practice Address - Street 1:1131 SAN FELIPE RD
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-2800
Practice Address - Country:US
Practice Address - Phone:415-269-9665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-12
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA848675163W00000X
FL9364333163W00000X
WA60427266163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse