Provider Demographics
NPI:1285106476
Name:VINNICHUK, TATYANA
Entity type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:VINNICHUK
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 1:1288 GRAND JUNCTION WAY
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-9285
Mailing Address - Country:US
Mailing Address - Phone:916-878-6364
Mailing Address - Fax:
Practice Address - Street 1:1600 EUREKA RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3027
Practice Address - Country:US
Practice Address - Phone:916-878-6364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23507235500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235500000XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistGroup - Single Specialty