Provider Demographics
NPI:1194286047
Name:O'NEIL-TENNANT, COLLEEN (MD)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:O'NEIL-TENNANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:757 WESTWOOD PLAZA, FAMILY MEDICINE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40595 WESTLAKE DR
Practice Address - Street 2:
Practice Address - City:OAKHURST
Practice Address - State:CA
Practice Address - Zip Code:93644-9024
Practice Address - Country:US
Practice Address - Phone:559-658-8388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA179168207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program