Provider Demographics
NPI:1497265839
Name:WARE, TANISHA SHANELLE (PTA)
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:SHANELLE
Last Name:WARE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 BRUCEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-5159
Mailing Address - Country:US
Mailing Address - Phone:910-384-0455
Mailing Address - Fax:
Practice Address - Street 1:101 BRUCEWOOD RD
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-5159
Practice Address - Country:US
Practice Address - Phone:910-692-4928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA5872225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant