Provider Demographics
NPI:1114524857
Name:ALLEY, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:ALLEY
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 1:355 BLUEFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-2883
Mailing Address - Country:US
Mailing Address - Phone:304-425-7111
Mailing Address - Fax:304-425-1138
Practice Address - Street 1:1277 STONEY RIDGE RD
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-4266
Practice Address - Country:US
Practice Address - Phone:304-920-5107
Practice Address - Fax:304-425-7111
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1568796027376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV55-6025355Medicaid