Provider Demographics
NPI:1164295101
Name:AUSTIN, TATIKQUA
Entity Type:Individual
Prefix:
First Name:TATIKQUA
Middle Name:
Last Name:AUSTIN
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 1:140 HUMBOLDT AVE APT 306
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02121-1258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 HUMBOLDT AVE APT 306
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02121-1258
Practice Address - Country:US
Practice Address - Phone:351-204-3097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-01
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
376J00000X
MA374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No376J00000XNursing Service Related ProvidersHomemaker