Provider Demographics
NPI:1710283759
Name:LANDIS, TAMALA
Entity Type:Individual
Prefix:
First Name:TAMALA
Middle Name:
Last Name:LANDIS
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 1272
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:CO
Mailing Address - Zip Code:80107-1272
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34061 FOREST PARK DR
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:CO
Practice Address - Zip Code:80107-7842
Practice Address - Country:US
Practice Address - Phone:303-646-4071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO712126376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide