Provider Demographics
NPI:1144737081
Name:KING, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:TINA
Other - Middle Name:M
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FISHER , BRENNAN
Mailing Address - Street 1:845 LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-2413
Mailing Address - Country:US
Mailing Address - Phone:740-607-4814
Mailing Address - Fax:
Practice Address - Street 1:845 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-2413
Practice Address - Country:US
Practice Address - Phone:740-607-4814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-01
Last Update Date:2018-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH318395Medicaid