Provider Demographics
NPI:1528468501
Name:FISHBACK, TAWNE (NNP)
Entity type:Individual
Prefix:
First Name:TAWNE
Middle Name:
Last Name:FISHBACK
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 MOSAIC WAY
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619-5156
Mailing Address - Country:US
Mailing Address - Phone:559-320-5570
Mailing Address - Fax:
Practice Address - Street 1:729 N MEDICAL CENTER DR W
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6879
Practice Address - Country:US
Practice Address - Phone:559-900-3045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000226363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care