Provider Demographics
NPI:1821625864
Name:KAVOUSSI, TANYA
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:KAVOUSSI
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 1:9854 FRANK RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38139-8000
Mailing Address - Country:US
Mailing Address - Phone:901-288-6299
Mailing Address - Fax:
Practice Address - Street 1:323 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2842
Practice Address - Country:US
Practice Address - Phone:310-392-4103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program