Provider Demographics
NPI:1235788415
Name:KING, TYNEISHIA CUNNINGHAM
Entity Type:Individual
Prefix:
First Name:TYNEISHIA
Middle Name:CUNNINGHAM
Last Name:KING
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 1:1207 E FORREST ST STE 204D
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35613-2057
Mailing Address - Country:US
Mailing Address - Phone:256-301-5405
Mailing Address - Fax:
Practice Address - Street 1:1207 E FORREST ST STE 204D
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35613-2057
Practice Address - Country:US
Practice Address - Phone:256-230-5280
Practice Address - Fax:256-427-4117
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL115157363LF0000X
AL1-115157363LP0200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009937074Medicaid