Provider Demographics
NPI:1629108998
Name:DAVID, TAMALA MIYAKO (RN, FNP)
Entity Type:Individual
Prefix:MRS
First Name:TAMALA
Middle Name:MIYAKO
Last Name:DAVID
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 DAKOTA ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14606-1335
Mailing Address - Country:US
Mailing Address - Phone:585-529-9936
Mailing Address - Fax:585-529-4599
Practice Address - Street 1:201 DAKOTA ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14606
Practice Address - Country:US
Practice Address - Phone:585-529-9936
Practice Address - Fax:585-529-4599
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF335068-1363LF0000X
NY515251-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02140632Medicaid