Provider Demographics
NPI:1346984606
Name:MODELISTE, TANIA JEANETTE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MRS
First Name:TANIA
Middle Name:JEANETTE
Last Name:MODELISTE
Suffix:
Gender:
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 NEWMARKET SQ
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23605-2721
Mailing Address - Country:US
Mailing Address - Phone:757-825-8030
Mailing Address - Fax:757-847-9149
Practice Address - Street 1:48 NEWMARKET SQ
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23605-2721
Practice Address - Country:US
Practice Address - Phone:757-825-8030
Practice Address - Fax:757-847-9149
Is Sole Proprietor?:No
Enumeration Date:2022-04-22
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAF11210527363LF0000X
OR202205372NP-PP363LF0000X
VA0024183611363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR202205372NP-PPOtherLICENSE