Provider Demographics
NPI:1760008908
Name:NEELY, TANYA
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:NEELY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:
Other - Last Name:MARSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6811 S 204TH ST
Mailing Address - Street 2:STE 280
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-1352
Mailing Address - Country:US
Mailing Address - Phone:360-749-9120
Mailing Address - Fax:
Practice Address - Street 1:1615 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2367
Practice Address - Country:US
Practice Address - Phone:360-636-4847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60137227163WC0200X
WAAP61127888363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine