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:MIA
Other - Middle Name:ROBERNETTE
Other - Last Name:JAMES
Other - Suffix:
Other - Last Name Type:Former Name
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:228-712-0396
Mailing Address - Fax:
Practice Address - Street 1:1 CVS DR
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-6195
Practice Address - Country:US
Practice Address - Phone:401-581-6303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-14
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS864476363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily