Provider Demographics
NPI:1528614401
Name:TAN, CONNIE
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:TAN
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 1:2301 NORTHGATE AVE APT 303
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-1782
Mailing Address - Country:US
Mailing Address - Phone:510-282-7627
Mailing Address - Fax:
Practice Address - Street 1:818 WEBSTER ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-4220
Practice Address - Country:US
Practice Address - Phone:510-986-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA273130164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse