Provider Demographics
NPI:1730921628
Name:ENRIQUEZ, CHEYENNE TUALLA
Entity type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:TUALLA
Last Name:ENRIQUEZ
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 1:300 BEL AIR DR APT 87
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-6321
Mailing Address - Country:US
Mailing Address - Phone:209-276-7369
Mailing Address - Fax:
Practice Address - Street 1:6203 SAN IGNACIO AVE STE 110
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119-1358
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician