Provider Demographics
NPI:1902903636
Name:MEAD, TANJA (MSN, FNP)
Entity Type:Individual
Prefix:MRS
First Name:TANJA
Middle Name:
Last Name:MEAD
Suffix:
Gender:F
Credentials:MSN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TRUMANN
Mailing Address - State:AR
Mailing Address - Zip Code:72472-3116
Mailing Address - Country:US
Mailing Address - Phone:870-483-1025
Mailing Address - Fax:870-483-1057
Practice Address - Street 1:417 W MAIN ST
Practice Address - Street 2:
Practice Address - City:TRUMANN
Practice Address - State:AR
Practice Address - Zip Code:72472-3116
Practice Address - Country:US
Practice Address - Phone:870-483-1025
Practice Address - Fax:870-483-1057
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA02930ANP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR185659758Medicaid