Healthcare Provider Details

I. General information

NPI: 1063290534
Provider Name (Legal Business Name): TANESHA FORD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 09/18/2023
Certification Date: 09/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 PUDDLEDOCK RD STE 300
PRINCE GEORGE VA
23875-1268
US

IV. Provider business mailing address

4700 PUDDLEDOCK RD STE 300
PRINCE GEORGE VA
23875-1268
US

V. Phone/Fax

Practice location:
  • Phone: 804-526-1111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024187907
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: