Provider Demographics
NPI:1447739081
Name:FRAZIER, TYNEKIA MARIE
Entity Type:Individual
Prefix:
First Name:TYNEKIA
Middle Name:MARIE
Last Name:FRAZIER
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 1:2210 LINE AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2134
Mailing Address - Country:US
Mailing Address - Phone:318-675-1112
Mailing Address - Fax:
Practice Address - Street 1:995 EAST RD APT 9
Practice Address - Street 2:
Practice Address - City:SAREPTA
Practice Address - State:LA
Practice Address - Zip Code:71071-2465
Practice Address - Country:US
Practice Address - Phone:318-639-1426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator