1265907075 NPI number — MS. TISA HEATH

Table of content: MS. TISA HEATH (NPI 1265907075)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265907075 NPI number — MS. TISA HEATH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEATH
Provider First Name:
TISA
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265907075
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/08/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1625 CONLEY RD APT 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONLEY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30288-1885
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-387-3040
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2135 TIFFANY LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITHONIA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30058-5320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-984-4984
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/08/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 172V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 81-4250548 . This is a "TID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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