Provider Demographics
NPI:1093919284
Name:THERIAULT, TANYA YVONNE (DO)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:YVONNE
Last Name:THERIAULT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 W LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-1836
Mailing Address - Country:US
Mailing Address - Phone:850-469-3500
Mailing Address - Fax:850-595-1400
Practice Address - Street 1:1221 W LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-1836
Practice Address - Country:US
Practice Address - Phone:850-469-3500
Practice Address - Fax:850-595-1400
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS112652084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005930800Medicaid
BP1-0026068OtherINSTITUTIONAL PERMIT
BP1-0026068OtherINSTITUTIONAL PERMIT