Provider Demographics
NPI:1407998909
Name:HODGE, TANYA RENEE (APRN-BC)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:RENEE
Last Name:HODGE
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3779
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32516-3779
Mailing Address - Country:US
Mailing Address - Phone:850-516-0486
Mailing Address - Fax:
Practice Address - Street 1:12385 SORRENTO RD STE D4
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32507-8656
Practice Address - Country:US
Practice Address - Phone:850-495-9467
Practice Address - Fax:850-492-6347
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2631892363LA2100X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015171000Medicaid
FLY7819OtherBLUE CROSS - FL
FLP00833129OtherRAILROAD MEDICARE
FLY7819OtherBLUE CROSS - FL
FL300814200Medicaid
FLE3866ZMedicare Oscar/Certification