Provider Demographics
NPI:1528415478
Name:FONDA, TANYISKA (NP-C)
Entity Type:Individual
Prefix:
First Name:TANYISKA
Middle Name:
Last Name:FONDA
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4370 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-1056
Mailing Address - Country:US
Mailing Address - Phone:334-794-5000
Mailing Address - Fax:
Practice Address - Street 1:4370 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1056
Practice Address - Country:US
Practice Address - Phone:334-794-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-20
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-104056363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner