Provider Demographics
NPI:1134655798
Name:LEGREE, TIA
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:LEGREE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TIA
Other - Middle Name:
Other - Last Name:OSBORNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:10925 KEY VEGA DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-4482
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10925 KEY VEGA DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4482
Practice Address - Country:US
Practice Address - Phone:904-414-1776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5207223164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse