Basic Information
| Provider Information | |||||||||
| NPI: | 1841625233 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAND | ||||||||
| FirstName: | TANYA | ||||||||
| MiddleName: | WADDLE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | APRN - NP, FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WADDLE | ||||||||
| OtherFirstName: | TANYA | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1502 N JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 646331948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6605421695 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1502 N JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 646331948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6605421695 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2013 | ||||||||
| LastUpdateDate: | 09/05/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2013032494 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.