Provider Demographics
NPI:1194218719
Name:TUNSTALL, DESIRAE
Entity Type:Individual
Prefix:
First Name:DESIRAE
Middle Name:
Last Name:TUNSTALL
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 1:5954 SHANA DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-9408
Mailing Address - Country:US
Mailing Address - Phone:614-813-4782
Mailing Address - Fax:
Practice Address - Street 1:895 PARSONS AVE STE B
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43206-2398
Practice Address - Country:US
Practice Address - Phone:614-705-1919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator