Provider Demographics
NPI:1114278769
Name:IVERSON, TAWANDA
Entity Type:Individual
Prefix:
First Name:TAWANDA
Middle Name:
Last Name:IVERSON
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 1:1050 WHITNEY RANCH DR APT 2824
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-3048
Mailing Address - Country:US
Mailing Address - Phone:323-802-5615
Mailing Address - Fax:
Practice Address - Street 1:1050 WHITNEY RANCH DR APT 2824
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-3048
Practice Address - Country:US
Practice Address - Phone:323-802-5615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-23
Last Update Date:2012-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty