Provider Demographics
NPI:1992547434
Name:TACDERAN, AMBER ASHLEY P
Entity type:Individual
Prefix:
First Name:AMBER ASHLEY
Middle Name:P
Last Name:TACDERAN
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 1:16254 LOZANO ST UNIT 3
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-6315
Mailing Address - Country:US
Mailing Address - Phone:909-275-4618
Mailing Address - Fax:
Practice Address - Street 1:815 S WILLOW AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-6934
Practice Address - Country:US
Practice Address - Phone:909-820-8150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95230119163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse