Individual
TATJANA ILICH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
1964 VIA CTR, VISTA, CA 92081-6056
(888) 743-7526
Mailing address
1964 VIA CTR, VISTA, CA 92081-6056
(888) 743-7526
Taxonomy
Speciality
Code
Description
License number
State
163WM0705X
Medical-Surgical Registered Nurse
95165114
CA
363LF0000X
Family Nurse Practitioner
95026030
CA
363LP2300X
Primary Care Nurse Practitioner
Primary
95026030
CA
Other
Enumeration date
07/18/2023
Last updated
02/05/2026
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