Provider Demographics
NPI:1740985878
Name:TAVAREZ, AMANDA ELYSE (RN)
Entity type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:ELYSE
Last Name:TAVAREZ
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10285 AGATE AVE
Mailing Address - Street 2:
Mailing Address - City:MENTONE
Mailing Address - State:CA
Mailing Address - Zip Code:92359-1378
Mailing Address - Country:US
Mailing Address - Phone:909-725-1985
Mailing Address - Fax:
Practice Address - Street 1:2038 W PARK AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-6260
Practice Address - Country:US
Practice Address - Phone:833-462-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-30
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95025355163W00000X
CA95030859363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse