Provider Demographics
NPI:1407609266
Name:HALIBURTON, TATICHIA (LPN)
Entity Type:Individual
Prefix:
First Name:TATICHIA
Middle Name:
Last Name:HALIBURTON
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 1:1051 CENTER STONE LN
Mailing Address - Street 2:
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33404-1825
Mailing Address - Country:US
Mailing Address - Phone:561-370-8622
Mailing Address - Fax:
Practice Address - Street 1:1051 CENTER STONE LN
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33404-1825
Practice Address - Country:US
Practice Address - Phone:561-370-8622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-10
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5171716164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse