Provider Demographics
NPI:1619364742
Name:LLANQUE, TANYA
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:LLANQUE
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 1:6901 S 84TH ST
Mailing Address - Street 2:
Mailing Address - City:LA VISTA
Mailing Address - State:NE
Mailing Address - Zip Code:68128-2127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6901 S 84TH ST
Practice Address - Street 2:
Practice Address - City:LA VISTA
Practice Address - State:NE
Practice Address - Zip Code:68128-2127
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-15
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE111778363LF0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily