Provider Demographics
NPI:1760146658
Name:HEINZ, TANNYA
Entity Type:Individual
Prefix:
First Name:TANNYA
Middle Name:
Last Name:HEINZ
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 1:1235 INDIANA CT STE 107
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-4540
Mailing Address - Country:US
Mailing Address - Phone:909-566-3358
Mailing Address - Fax:909-757-6400
Practice Address - Street 1:1235 INDIANA CT STE 107
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-4540
Practice Address - Country:US
Practice Address - Phone:909-566-3358
Practice Address - Fax:909-757-6400
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-26
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center