Provider Demographics
NPI:1346984606
Name:MODELISTE, TANIA JEANETTE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:TANIA
Middle Name:JEANETTE
Last Name:MODELISTE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1778 NE CORNELL RD
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-2740
Mailing Address - Country:US
Mailing Address - Phone:855-722-9700
Mailing Address - Fax:844-222-0800
Practice Address - Street 1:1778 NE CORNELL RD
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-2740
Practice Address - Country:US
Practice Address - Phone:855-722-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-22
Last Update Date:2022-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAF11210527363LF0000X
OR202205372NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR202205372NP-PPOtherLICENSE