Provider Demographics
NPI:1144926049
Name:TAN, AUDREY JOHANNA Y
Entity type:Individual
Prefix:
First Name:AUDREY JOHANNA
Middle Name:Y
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 1:3149 ANTONIO AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619-8907
Mailing Address - Country:US
Mailing Address - Phone:714-390-8761
Mailing Address - Fax:
Practice Address - Street 1:517 S A ST
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93638-3806
Practice Address - Country:US
Practice Address - Phone:714-390-8761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11003225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist