Provider Demographics
NPI:1801123914
Name:WEGRZYN, TAMMY RENEE (NP)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:RENEE
Last Name:WEGRZYN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6674 LEANNE ST
Mailing Address - Street 2:
Mailing Address - City:MIRA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91752-3478
Mailing Address - Country:US
Mailing Address - Phone:951-990-1230
Mailing Address - Fax:
Practice Address - Street 1:11705 SLATE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-5196
Practice Address - Country:US
Practice Address - Phone:800-274-3893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-10
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19081363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily