Provider Demographics
NPI:1366816498
Name:REDICK, TINA (LPN)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:REDICK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 W FALLS RD
Mailing Address - Street 2:
Mailing Address - City:WEST FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14170-9711
Mailing Address - Country:US
Mailing Address - Phone:716-425-0289
Mailing Address - Fax:
Practice Address - Street 1:522 W FALLS RD
Practice Address - Street 2:
Practice Address - City:WEST FALLS
Practice Address - State:NY
Practice Address - Zip Code:14170-9711
Practice Address - Country:US
Practice Address - Phone:716-425-0289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-01
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY179999164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse