Healthcare Provider Details

I. General information

NPI: 1053795435
Provider Name (Legal Business Name): TINA S. CHAVIS FNP, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2015
Last Update Date: 06/11/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 748465
ATLANTA GA
30374-8465
US

IV. Provider business mailing address

3074 DOGWOOD LN
RICHMOND IN
47374-3531
US

V. Phone/Fax

Practice location:
  • Phone: 855-284-7483
  • Fax:
Mailing address:
  • Phone: 765-967-0466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28184688A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number71005603A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71005603A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: