Provider Demographics
NPI:1841625233
Name:LAND, TANYA WADDLE (APRN - NP, FNP-C)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:WADDLE
Last Name:LAND
Suffix:
Gender:F
Credentials:APRN - NP, FNP-C
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:ANN
Other - Last Name:WADDLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1502 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:MO
Mailing Address - Zip Code:64633-1948
Mailing Address - Country:US
Mailing Address - Phone:660-542-1695
Mailing Address - Fax:
Practice Address - Street 1:1502 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:MO
Practice Address - Zip Code:64633-1948
Practice Address - Country:US
Practice Address - Phone:660-542-1695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013032494363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420008231Medicaid