Provider Demographics
NPI:1215749296
Name:TAMAYO, MICHELLE LYNN
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:LYNN
Last Name:TAMAYO
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 1:4006 VAN BUREN PL
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-2828
Mailing Address - Country:US
Mailing Address - Phone:520-461-9399
Mailing Address - Fax:
Practice Address - Street 1:8635 W 3RD ST STE 355
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-6112
Practice Address - Country:US
Practice Address - Phone:323-655-7610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-24
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95030480363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner