Provider Demographics
NPI:1073210829
Name:CONVER, TIKISHA
Entity Type:Individual
Prefix:
First Name:TIKISHA
Middle Name:
Last Name:CONVER
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 1:1125 17TH ST NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44705-1264
Mailing Address - Country:US
Mailing Address - Phone:440-529-4563
Mailing Address - Fax:
Practice Address - Street 1:1125 17TH ST NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44705-1264
Practice Address - Country:US
Practice Address - Phone:440-529-4563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
376K00000X
OH400738830408376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide