Provider Demographics
NPI:1699808378
Name:ROBERTS, TENNILLE RENEE (CAS)
Entity type:Individual
Prefix:
First Name:TENNILLE
Middle Name:RENEE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:CAS
Other - Prefix:
Other - First Name:TENNILLE
Other - Middle Name:RENEE
Other - Last Name:DE LA TORRE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:7000 LEISURE TOWN RD
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-9413
Mailing Address - Country:US
Mailing Address - Phone:707-249-1062
Mailing Address - Fax:707-453-0384
Practice Address - Street 1:2101 COURAGE DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-6717
Practice Address - Country:US
Practice Address - Phone:707-784-2057
Practice Address - Fax:707-427-2981
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA03-061421372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA03-061421OtherCAS