Provider Demographics
NPI:1750926788
Name:FASTNACHT, TANYA MARIE
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:MARIE
Last Name:FASTNACHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:MARIE
Other - Last Name:FRANDSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:337 LARKSPUR ST
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-4429
Mailing Address - Country:US
Mailing Address - Phone:425-501-4808
Mailing Address - Fax:
Practice Address - Street 1:1400 N NORMA ST
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-2575
Practice Address - Country:US
Practice Address - Phone:760-463-5053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator