Provider Demographics
NPI:1710318266
Name:NKWEN-TAMO, YVONNE
Entity Type:Individual
Prefix:
First Name:YVONNE
Middle Name:
Last Name:NKWEN-TAMO
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 1:1775 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-5732
Mailing Address - Country:US
Mailing Address - Phone:928-763-8771
Mailing Address - Fax:928-973-1868
Practice Address - Street 1:1775 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-5732
Practice Address - Country:US
Practice Address - Phone:928-763-8771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS020161183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist