Provider Demographics
NPI:1356815617
Name:TANIS, LOURDY P (APRN)
Entity Type:Individual
Prefix:
First Name:LOURDY
Middle Name:P
Last Name:TANIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3405 NW FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-4439
Mailing Address - Country:US
Mailing Address - Phone:772-692-8082
Mailing Address - Fax:
Practice Address - Street 1:7195 S GEORGE BLVD FL 33875
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33875-5823
Practice Address - Country:US
Practice Address - Phone:863-304-8838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP-925656571363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily