Provider Demographics
NPI:1235257304
Name:CARPENTER, TANIYA (RN)
Entity Type:Individual
Prefix:MRS
First Name:TANIYA
Middle Name:
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 RECOVERY RD
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-3235
Mailing Address - Country:US
Mailing Address - Phone:573-888-2831
Mailing Address - Fax:573-888-5408
Practice Address - Street 1:402 RECOVERY RD
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-3235
Practice Address - Country:US
Practice Address - Phone:573-888-2831
Practice Address - Fax:573-888-5408
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO130959163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO130959Medicaid