Provider Demographics
NPI:1740983733
Name:CHARLES, TANESHA SHANEY (MS, AGACNP)
Entity type:Individual
Prefix:
First Name:TANESHA
Middle Name:SHANEY
Last Name:CHARLES
Suffix:
Gender:F
Credentials:MS, AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5311 LIONS GATE LN
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-5639
Mailing Address - Country:US
Mailing Address - Phone:512-887-8372
Mailing Address - Fax:
Practice Address - Street 1:301 SETON PKWY STE 402
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-8003
Practice Address - Country:US
Practice Address - Phone:512-324-4816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1103776363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care