Provider Demographics
NPI:1023374618
Name:MIMS, TEQUA
Entity Type:Individual
Prefix:
First Name:TEQUA
Middle Name:
Last Name:MIMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6309 ALTHORP CV
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:TN
Mailing Address - Zip Code:38002-7005
Mailing Address - Country:US
Mailing Address - Phone:901-487-9653
Mailing Address - Fax:901-829-7766
Practice Address - Street 1:6309 ALTHORP CV
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:TN
Practice Address - Zip Code:38002-7005
Practice Address - Country:US
Practice Address - Phone:901-487-9653
Practice Address - Fax:901-829-7766
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-08
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN091404354343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)