Provider Demographics
NPI:1174515423
Name:FALLEN, TINA BROCK (ARNP)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:BROCK
Last Name:FALLEN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 748817
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8817
Mailing Address - Country:US
Mailing Address - Phone:813-286-0033
Mailing Address - Fax:813-286-0033
Practice Address - Street 1:515 S KINGS AVE STE 3100
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6060
Practice Address - Country:US
Practice Address - Phone:813-681-9171
Practice Address - Fax:813-681-7580
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLARNP3394792363LW0102X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health