Provider Demographics
NPI:1386766400
Name:WHITAKER, TANA MAE
Entity type:Individual
Prefix:
First Name:TANA
Middle Name:MAE
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TANA
Other - Middle Name:
Other - Last Name:WHITAKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMP
Mailing Address - Street 1:121 PELLY AVE N
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-5714
Mailing Address - Country:US
Mailing Address - Phone:425-271-2389
Mailing Address - Fax:425-271-2389
Practice Address - Street 1:121 PELLY AVE N
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-5714
Practice Address - Country:US
Practice Address - Phone:425-271-2389
Practice Address - Fax:425-271-2389
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00010537174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist