Provider Demographics
NPI:1457112906
Name:OLIVENCIA GONZALEZ, TANAIRY
Entity Type:Individual
Prefix:
First Name:TANAIRY
Middle Name:
Last Name:OLIVENCIA GONZALEZ
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:PO BOX 961
Mailing Address - Street 2:
Mailing Address - City:PENUELAS
Mailing Address - State:PR
Mailing Address - Zip Code:00624-0961
Mailing Address - Country:US
Mailing Address - Phone:787-462-4804
Mailing Address - Fax:
Practice Address - Street 1:URB SANTO DOMINGO 2
Practice Address - Street 2:PARCELA 157
Practice Address - City:PENUELAS
Practice Address - State:PR
Practice Address - Zip Code:00624
Practice Address - Country:US
Practice Address - Phone:787-462-4804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR101042163W00000X, 163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency
No163W00000XNursing Service ProvidersRegistered Nurse