Provider Demographics
NPI:1841712049
Name:TANAKA, CAITLINN KUUIPO (LPN)
Entity type:Individual
Prefix:
First Name:CAITLINN
Middle Name:KUUIPO
Last Name:TANAKA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4835 TRENT ST
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2955
Mailing Address - Country:US
Mailing Address - Phone:208-241-6815
Mailing Address - Fax:
Practice Address - Street 1:4835 TRENT ST
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2955
Practice Address - Country:US
Practice Address - Phone:208-241-6815
Practice Address - Fax:208-241-6815
Is Sole Proprietor?:No
Enumeration Date:2017-07-10
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPN-46661164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse