Provider Demographics
NPI:1598542003
Name:TABOADA, ALICIA
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:TABOADA
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:PO BOX 5394
Mailing Address - Street 2:
Mailing Address - City:PINE MOUNTAIN CLUB
Mailing Address - State:CA
Mailing Address - Zip Code:93222-5394
Mailing Address - Country:US
Mailing Address - Phone:661-699-7933
Mailing Address - Fax:
Practice Address - Street 1:1030 S GLENDALE AVE STE 200
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-2866
Practice Address - Country:US
Practice Address - Phone:818-850-5667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95026644363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily