Provider Demographics
NPI:1083349534
Name:WOOD, TISHA J
Entity Type:Individual
Prefix:
First Name:TISHA
Middle Name:J
Last Name:WOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TISHA
Other - Middle Name:J
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:61 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-1854
Mailing Address - Country:US
Mailing Address - Phone:125-232-6577
Mailing Address - Fax:
Practice Address - Street 1:61 MADISON ST
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-1854
Practice Address - Country:US
Practice Address - Phone:125-232-6577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000038608717172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver