Provider Demographics
NPI:1902016454
Name:LEAMON, TANYA
Entity Type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:
Last Name:LEAMON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:TANYA
Other - Middle Name:
Other - Last Name:IVERY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1526 W SAINT ANNE AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-5819
Mailing Address - Country:US
Mailing Address - Phone:602-323-9635
Mailing Address - Fax:
Practice Address - Street 1:1526 W SAINT ANNE AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-5819
Practice Address - Country:US
Practice Address - Phone:602-323-9635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8274171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor