Provider Demographics
NPI:1790431708
Name:WILSON, TANYA (LVN)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 FULTON AVE STE 235
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-4299
Mailing Address - Country:US
Mailing Address - Phone:916-614-9539
Mailing Address - Fax:916-614-9542
Practice Address - Street 1:1050 FULTON AVE STE 235
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-4299
Practice Address - Country:US
Practice Address - Phone:916-614-9539
Practice Address - Fax:916-614-9542
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN687200167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician