Provider Demographics
NPI:1487414298
Name:ESPELITA, FAIR ANTONETTE TANADA (RN, CPN)
Entity type:Individual
Prefix:MRS
First Name:FAIR ANTONETTE
Middle Name:TANADA
Last Name:ESPELITA
Suffix:
Gender:F
Credentials:RN, CPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1053 RAYNOR ST
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-7520
Mailing Address - Country:US
Mailing Address - Phone:909-735-1121
Mailing Address - Fax:
Practice Address - Street 1:1053 RAYNOR ST
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-7520
Practice Address - Country:US
Practice Address - Phone:909-735-1121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA671069163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management