Provider Demographics
NPI:1255916375
Name:VANN, TEILANI
Entity type:Individual
Prefix:
First Name:TEILANI
Middle Name:
Last Name:VANN
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 1:202 E PUENTE ST
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-3003
Mailing Address - Country:US
Mailing Address - Phone:951-512-2168
Mailing Address - Fax:
Practice Address - Street 1:677 CLIFFSIDE DR
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2957
Practice Address - Country:US
Practice Address - Phone:626-345-6455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
20119035OtherKAISER PERMANENTE