Provider Demographics
NPI:1508640517
Name:ATKINS, TIESHA RENEA
Entity Type:Individual
Prefix:
First Name:TIESHA
Middle Name:RENEA
Last Name:ATKINS
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 1:6911 HOLLY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-3024
Mailing Address - Country:US
Mailing Address - Phone:502-794-3861
Mailing Address - Fax:
Practice Address - Street 1:6911 HOLLY LAKE DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-3024
Practice Address - Country:US
Practice Address - Phone:502-794-3861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1151972163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse