Provider Demographics
NPI:1275172827
Name:PATTERSON, TINA MONE (COSMETOLOGIST)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MONE
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:COSMETOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 SAN JUAN DR
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75116-3921
Mailing Address - Country:US
Mailing Address - Phone:254-531-1057
Mailing Address - Fax:
Practice Address - Street 1:8501 OLD HICKORY TRL APT 2106
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-3821
Practice Address - Country:US
Practice Address - Phone:254-531-1057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-31
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1792338174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1792338OtherTEXAS BOARD OF LICENSING AND REGULATION