Healthcare Provider Details

I. General information

NPI: 1548726136
Provider Name (Legal Business Name): TANYA TAMIKA JENKINS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2019
Last Update Date: 09/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S MAIN ST
CRESTVIEW FL
32536-3737
US

IV. Provider business mailing address

210 S MAIN ST
CRESTVIEW FL
32536-3737
US

V. Phone/Fax

Practice location:
  • Phone: 850-226-6801
  • Fax: 877-413-5104
Mailing address:
  • Phone: 850-226-6801
  • Fax: 877-413-5104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-103793
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11001999
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: