Provider Demographics
NPI:1720031453
Name:TANIS, KATHRYN (CNP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:TANIS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9512 ALLANDE RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-6618
Mailing Address - Country:US
Mailing Address - Phone:505-299-2148
Mailing Address - Fax:505-299-2148
Practice Address - Street 1:883 LEAD AVE SE
Practice Address - Street 2:STE A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3644
Practice Address - Country:US
Practice Address - Phone:505-247-8820
Practice Address - Fax:505-246-9421
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP00550363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM51452715Medicaid
NM344405602Medicare PIN
NMQ04149Medicare UPIN