Provider Demographics
NPI:1417696972
Name:SPRATLIN, TIERRA DESHAYE
Entity Type:Individual
Prefix:
First Name:TIERRA
Middle Name:DESHAYE
Last Name:SPRATLIN
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 1:1507 PINE DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-6169
Mailing Address - Country:US
Mailing Address - Phone:470-812-1105
Mailing Address - Fax:
Practice Address - Street 1:1507 PINE DR APT J15
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-6936
Practice Address - Country:US
Practice Address - Phone:470-812-1105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049783280343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)