Provider Demographics
NPI:1699468850
Name:GREENWADE, TAHJANIERA A (LVN)
Entity type:Individual
Prefix:
First Name:TAHJANIERA
Middle Name:A
Last Name:GREENWADE
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 CALLE DEL CERRO APT 149L
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-6029
Mailing Address - Country:US
Mailing Address - Phone:502-203-7762
Mailing Address - Fax:
Practice Address - Street 1:1100 CALLE DEL CERRO APT 149L
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-6029
Practice Address - Country:US
Practice Address - Phone:502-203-7762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA733672164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse