Provider Demographics
NPI:1124526025
Name:ANDERSON, TANISHA (DNP, APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:TANISHA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DNP, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7055 BLANDING BLVD
Mailing Address - Street 2:P.O.BOX 440242
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32222
Mailing Address - Country:US
Mailing Address - Phone:904-638-3511
Mailing Address - Fax:
Practice Address - Street 1:7643 GATE PKWY STE 104-523
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-2893
Practice Address - Country:US
Practice Address - Phone:904-638-3511
Practice Address - Fax:424-999-0307
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9297657363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRN9297657OtherRN FL LICENSE
FLAPRN9297657OtherAPRN FL LICENSE
FLMA4881098OtherFED DEA