Provider Demographics
NPI:1063838480
Name:COCKRELL, TANYA (FNP)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:COCKRELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 MILITARY RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39701-3616
Mailing Address - Country:US
Mailing Address - Phone:662-630-5001
Mailing Address - Fax:
Practice Address - Street 1:1324 MILITARY RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39701-3616
Practice Address - Country:US
Practice Address - Phone:662-630-5001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-10
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR874320363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02928257Medicaid
MS361340YP5RMedicare PIN