Provider Demographics
NPI:1114509726
Name:HOLSTON, TEAIRA RENEE
Entity Type:Individual
Prefix:
First Name:TEAIRA
Middle Name:RENEE
Last Name:HOLSTON
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 1:10 HEFFRON DR APT 13
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-7710
Mailing Address - Country:US
Mailing Address - Phone:513-442-6721
Mailing Address - Fax:
Practice Address - Street 1:10 HEFFRON DR APT 13
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-7710
Practice Address - Country:US
Practice Address - Phone:513-442-6721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No172A00000XOther Service ProvidersDriverGroup - Multi-Specialty