Provider Demographics
NPI:1801378310
Name:TKAC, RAFAELLE W
Entity type:Individual
Prefix:
First Name:RAFAELLE
Middle Name:W
Last Name:TKAC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 W BAY AREA BLVD STE 116
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-3404
Mailing Address - Country:US
Mailing Address - Phone:346-617-8993
Mailing Address - Fax:
Practice Address - Street 1:1507 W BAY AREA BLVD STE 116
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-3404
Practice Address - Country:US
Practice Address - Phone:346-617-8993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2024-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX940461163WP0200X
TX1111882363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WP0200XNursing Service ProvidersRegistered NursePediatrics