Provider Demographics
NPI:1063036051
Name:BOONE, KIANNA TYMORIA
Entity Type:Individual
Prefix:
First Name:KIANNA
Middle Name:TYMORIA
Last Name:BOONE
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 1:608 S LEE ST
Mailing Address - Street 2:
Mailing Address - City:FITZGERALD
Mailing Address - State:GA
Mailing Address - Zip Code:31750-3217
Mailing Address - Country:US
Mailing Address - Phone:229-472-2246
Mailing Address - Fax:
Practice Address - Street 1:608 S LEE ST
Practice Address - Street 2:
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750-3217
Practice Address - Country:US
Practice Address - Phone:229-472-2246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA318-10178246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA20070770OtherARTICLE OF ORGANIZATION