Provider Demographics
NPI:1225323322
Name:HULLUM, TANYA R (STNA)
Entity Type:Individual
Prefix:MS
First Name:TANYA
Middle Name:R
Last Name:HULLUM
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1861 W 58TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102-3252
Mailing Address - Country:US
Mailing Address - Phone:216-536-1712
Mailing Address - Fax:
Practice Address - Street 1:1861 W 58TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-3252
Practice Address - Country:US
Practice Address - Phone:216-536-1712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376978051197376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3134370Medicaid