Provider Demographics
NPI:1013417922
Name:LEE MCMILLIAN, TI'ARRA DOMINIQUE (LPN)
Entity Type:Individual
Prefix:MS
First Name:TI'ARRA
Middle Name:DOMINIQUE
Last Name:LEE MCMILLIAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5038 TEMPLE HEIGHTS RD APT 30
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617-4626
Mailing Address - Country:US
Mailing Address - Phone:813-451-5605
Mailing Address - Fax:
Practice Address - Street 1:2212 E HENRY AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-4433
Practice Address - Country:US
Practice Address - Phone:813-239-8069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-16
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5226312164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty