Provider Demographics
NPI:1407507221
Name:BLAIR, TINA MICHELLE (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MICHELLE
Last Name:BLAIR
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:MICHELLE
Other - Last Name:BLAIR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:500 HIGHWAY 51 S
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:TN
Mailing Address - Zip Code:38063-4583
Mailing Address - Country:US
Mailing Address - Phone:731-635-9711
Mailing Address - Fax:731-635-6031
Practice Address - Street 1:500 HIGHWAY 51 S
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:TN
Practice Address - Zip Code:38063-4583
Practice Address - Country:US
Practice Address - Phone:731-635-9711
Practice Address - Fax:731-635-6031
Is Sole Proprietor?:No
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000238667163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse