Provider Demographics
NPI:1306626254
Name:FREDOCK, TANYA HINTZ
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:HINTZ
Last Name:FREDOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:HINTZ
Other - Last Name:RATELLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5290 S POWER RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-8478
Mailing Address - Country:US
Mailing Address - Phone:480-988-9287
Mailing Address - Fax:480-988-9769
Practice Address - Street 1:5290 S POWER RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-8478
Practice Address - Country:US
Practice Address - Phone:480-988-9287
Practice Address - Fax:480-988-9769
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3202156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician