Provider Demographics
NPI:1710538061
Name:TULLOS, TANYA WILSON (NP-C)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:WILSON
Last Name:TULLOS
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 1:1001 HOLLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-2161
Mailing Address - Country:US
Mailing Address - Phone:601-781-2234
Mailing Address - Fax:601-781-2231
Practice Address - Street 1:1001 HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-2161
Practice Address - Country:US
Practice Address - Phone:601-781-2234
Practice Address - Fax:601-781-2231
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-26
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904858363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily