Provider Demographics
NPI:1457937146
Name:TANNEBAUM, CLARICE (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:CLARICE
Middle Name:
Last Name:TANNEBAUM
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALAMANCA
Mailing Address - State:NY
Mailing Address - Zip Code:14779-1227
Mailing Address - Country:US
Mailing Address - Phone:716-359-7175
Mailing Address - Fax:
Practice Address - Street 1:225 S CASCADE DR
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:14141-9287
Practice Address - Country:US
Practice Address - Phone:716-599-1163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR247845363LF0000X
NY347606363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily