Healthcare Provider Details

I. General information

NPI: 1720697477
Provider Name (Legal Business Name): TANISHA FIONA HYATT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TANISHA F POWELL

II. Dates (important events)

Enumeration Date: 07/29/2020
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 BULLARD PKWY STE A
TEMPLE TERRACE FL
33617-5543
US

IV. Provider business mailing address

901 MCCLINTOCK DR STE 202
BURR RIDGE IL
60527-0872
US

V. Phone/Fax

Practice location:
  • Phone: 877-448-3627
  • Fax: 866-507-1164
Mailing address:
  • Phone: 630-655-6748
  • Fax: 630-734-4715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11007827
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: