Provider Demographics
NPI:1528505922
Name:MICHELLE, TANYA (LAC RN HTP CST MOM)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:MICHELLE
Suffix:
Gender:F
Credentials:LAC RN HTP CST MOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 N COLLEGE AVE APT 2072
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-0193
Mailing Address - Country:US
Mailing Address - Phone:612-888-6666
Mailing Address - Fax:
Practice Address - Street 1:10304 N HAYDEN RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-1217
Practice Address - Country:US
Practice Address - Phone:612-888-3666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-23
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 121581-0163W00000X
AZ239494163W00000X
MN1834171100000X
AZLAC-010140171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN621399OtherNAICS
MN4841294OtherSTATE TAX ID #
MN621399OtherNAICS