Provider Demographics
NPI:1063639086
Name:TYREE, CHAUNETTA CECILIA
Entity Type:Individual
Prefix:
First Name:CHAUNETTA
Middle Name:CECILIA
Last Name:TYREE
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 1:2429 LINDEN AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-4540
Mailing Address - Country:US
Mailing Address - Phone:410-669-0522
Mailing Address - Fax:
Practice Address - Street 1:2429 LINDEN AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-4540
Practice Address - Country:US
Practice Address - Phone:410-669-0522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00016799376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide