Provider Demographics
NPI:1356888051
Name:LELAVITH, TAMMY (FNP)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:LELAVITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21201 VICTORY BLVD STE 154
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91303-4051
Mailing Address - Country:US
Mailing Address - Phone:866-445-8267
Mailing Address - Fax:
Practice Address - Street 1:21201 VICTORY BLVD STE 154
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-4051
Practice Address - Country:US
Practice Address - Phone:866-445-8267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003254363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily