Provider Demographics
NPI:1245100668
Name:TABOR, DERANEE PEARL G
Entity type:Individual
Prefix:MRS
First Name:DERANEE PEARL
Middle Name:G
Last Name:TABOR
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 1:541 S HAM LN STE A&B
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-3059
Mailing Address - Country:US
Mailing Address - Phone:209-224-8940
Mailing Address - Fax:
Practice Address - Street 1:541 S HAM LN STE A&B
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3059
Practice Address - Country:US
Practice Address - Phone:209-224-8940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-10
Last Update Date:2025-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA704752164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse