Provider Demographics
NPI:1508322421
Name:YORK, TIAH RAE (FNP-C)
Entity Type:Individual
Prefix:
First Name:TIAH
Middle Name:RAE
Last Name:YORK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 TIAK CHITTO DR
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-4068
Mailing Address - Country:US
Mailing Address - Phone:601-650-6281
Mailing Address - Fax:
Practice Address - Street 1:210 HOSPITAL CIR
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:MS
Practice Address - Zip Code:39350-6781
Practice Address - Country:US
Practice Address - Phone:601-389-4370
Practice Address - Fax:601-389-4372
Is Sole Proprietor?:No
Enumeration Date:2019-02-15
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS879903163W00000X
MSF02190023363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse