Provider Demographics
NPI:1730615295
Name:JOAB, TATYANA MARY JACQUI (MD)
Entity type:Individual
Prefix:
First Name:TATYANA
Middle Name:MARY JACQUI
Last Name:JOAB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3877
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60434-3877
Mailing Address - Country:US
Mailing Address - Phone:815-741-6830
Mailing Address - Fax:
Practice Address - Street 1:915 CLINGAN RIDGE DR NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-3729
Practice Address - Country:US
Practice Address - Phone:423-339-3340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN64989207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program