Provider Demographics
NPI:1982240891
Name:ANDERSEN, TATYANA
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:ANDERSEN
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:NAVAL HEALTH CLINIC HAWAII 480 CENTRAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:PEARL HARBOR
Mailing Address - State:HAWAII
Mailing Address - Zip Code:96860
Mailing Address - Country:UM
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:NAVAL HEALTH CLINIC HAWAII 480 CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:PEARL HARBOR
Practice Address - State:HAWAII
Practice Address - Zip Code:96860
Practice Address - Country:US
Practice Address - Phone:808-473-0650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-26
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR225654363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health