Provider Demographics
NPI:1376193094
Name:TAIT, MIA ROBERNETTE (FNP-C)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:ROBERNETTE
Last Name:TAIT
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14601 CONSTITUTION RD
Mailing Address - Street 2:
Mailing Address - City:MOSS POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39562-6375
Mailing Address - Country:US
Mailing Address - Phone:251-776-2015
Mailing Address - Fax:
Practice Address - Street 1:215 KATHERINE DR STE A
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9588
Practice Address - Country:US
Practice Address - Phone:601-665-4162
Practice Address - Fax:888-398-1151
Is Sole Proprietor?:No
Enumeration Date:2019-09-14
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS864476363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily