Provider Demographics
NPI:1376207969
Name:MINGO, TESSA REE
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:REE
Last Name:MINGO
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 1:2030 TOWNE PARK DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252
Mailing Address - Country:US
Mailing Address - Phone:662-542-4464
Mailing Address - Fax:
Practice Address - Street 1:4912 BILL GARDNER PARKWAY
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248-3025
Practice Address - Country:US
Practice Address - Phone:662-542-4644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAC0138190224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist