Healthcare Provider Details

I. General information

NPI: 1902903636
Provider Name (Legal Business Name): TANJA MEAD MSN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 W MAIN ST
TRUMANN AR
72472-3116
US

IV. Provider business mailing address

417 W MAIN ST
TRUMANN AR
72472-3116
US

V. Phone/Fax

Practice location:
  • Phone: 870-483-1025
  • Fax: 870-483-1057
Mailing address:
  • Phone: 870-483-1025
  • Fax: 870-483-1057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA02930ANP
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: