Healthcare Provider Details

I. General information

NPI: 1124525225
Provider Name (Legal Business Name): TANISHA MCNEAL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2018
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 FLORIDA AVE STE A
MODESTO CA
95350-4437
US

IV. Provider business mailing address

737 W CHILDS AVE
MERCED CA
95341-6805
US

V. Phone/Fax

Practice location:
  • Phone: 866-682-4842
  • Fax:
Mailing address:
  • Phone: 866-682-4842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number776580
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95015607
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: