Provider Demographics
NPI:1699808378
Name:ROBERTS, TENNILLE RENEE (CAS)
Entity Type:Individual
Prefix:
First Name:TENNILLE
Middle Name:RENEE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:CAS
Other - Prefix:
Other - First Name:TENNILLE
Other - Middle Name:RENEE
Other - Last Name:DE LA TORRE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:7000 LEISURE TOWN RD
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-9413
Mailing Address - Country:US
Mailing Address - Phone:707-249-1062
Mailing Address - Fax:707-453-0384
Practice Address - Street 1:15450 COUNTY ROAD 99
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-9339
Practice Address - Country:US
Practice Address - Phone:530-668-9627
Practice Address - Fax:530-668-8528
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA03-061421174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA03-061421OtherCAS