Provider Demographics
NPI:1770548075
Name:MAIN, TANETTA C (RN, FNP)
Entity type:Individual
Prefix:
First Name:TANETTA
Middle Name:C
Last Name:MAIN
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:TANETTA
Other - Middle Name:C
Other - Last Name:HOVEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2000 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52556-9572
Mailing Address - Country:US
Mailing Address - Phone:641-672-3360
Mailing Address - Fax:
Practice Address - Street 1:410 N 12TH ST
Practice Address - Street 2:
Practice Address - City:OSKALOOSA
Practice Address - State:IA
Practice Address - Zip Code:52577-2495
Practice Address - Country:US
Practice Address - Phone:641-672-3360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA-112035363LF0000X
MO2000167490363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
36800048OtherBCBS
MO540568508Medicaid
MO595956103Medicaid
MO599225901Medicaid
MO420721300Medicaid
MO010568509Medicaid
36800018OtherBCBS
MO595956202Medicaid
MO595956400Medicaid
MO595985805Medicaid
261320Medicare PIN
MO595956400Medicaid
MO540568508Medicaid
MO420721300Medicaid
MO595956202Medicaid
MO595956103Medicaid
268549Medicare Oscar/Certification
P270000Medicare PIN