Provider Demographics
NPI:1053919084
Name:ST JOHN, TAMRA ELLEN (LVN)
Entity type:Individual
Prefix:
First Name:TAMRA
Middle Name:ELLEN
Last Name:ST JOHN
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 BALBOA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1310
Mailing Address - Country:US
Mailing Address - Phone:419-260-3262
Mailing Address - Fax:
Practice Address - Street 1:171 BALBOA AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1310
Practice Address - Country:US
Practice Address - Phone:419-260-3262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA713484164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse