Provider Demographics
NPI:1578573432
Name:NUNNOLD, TANJA (PA)
Entity Type:Individual
Prefix:MS
First Name:TANJA
Middle Name:
Last Name:NUNNOLD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:TANJA
Other - Middle Name:
Other - Last Name:NUNNOLD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:291 INDEPENDENCE BLVD
Mailing Address - Street 2:PEMBROKE BLDG 4 STE 522
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462
Mailing Address - Country:US
Mailing Address - Phone:757-490-6637
Mailing Address - Fax:757-490-6636
Practice Address - Street 1:291 INDEPENDENCE BLVD
Practice Address - Street 2:PEMBROKE BLDG 4 STE 522
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462
Practice Address - Country:US
Practice Address - Phone:757-490-6637
Practice Address - Fax:757-490-6636
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002120363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA01000002120OtherSTATE LICENSE
VA01000002120OtherSTATE LICENSE