Provider Demographics
NPI:1285752444
Name:CHAMPA, TANYA R (BSN, MS, FNP)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:R
Last Name:CHAMPA
Suffix:
Gender:F
Credentials:BSN, MS, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 STARLIGHT PASS
Mailing Address - Street 2:
Mailing Address - City:HEATH
Mailing Address - State:TX
Mailing Address - Zip Code:75032-5984
Mailing Address - Country:US
Mailing Address - Phone:815-439-8043
Mailing Address - Fax:469-800-3110
Practice Address - Street 1:763 E US HIGHWAY 80 STE 240
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-8677
Practice Address - Country:US
Practice Address - Phone:469-800-3870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP128037363LF0000X
IL209006485174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Not Answered174400000XOther Service ProvidersSpecialist