Provider Demographics
NPI:1164845855
Name:DOUGLASS, TASHA
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:
Last Name:DOUGLASS
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 1:25 HEFFRON DR APT 9
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-7720
Mailing Address - Country:US
Mailing Address - Phone:513-805-6564
Mailing Address - Fax:
Practice Address - Street 1:25 HEFFRON DR APT 9
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-7720
Practice Address - Country:US
Practice Address - Phone:513-805-6564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401549410713374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide