Provider Demographics
NPI:1518232289
Name:DODGE, TYLEIGH
Entity Type:Individual
Prefix:
First Name:TYLEIGH
Middle Name:
Last Name:DODGE
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 1:1304 NASHVILLE RD
Mailing Address - Street 2:
Mailing Address - City:HORSESHOE BEND
Mailing Address - State:AR
Mailing Address - Zip Code:72512-3110
Mailing Address - Country:US
Mailing Address - Phone:870-750-0694
Mailing Address - Fax:
Practice Address - Street 1:1304 NASHVILLE RD
Practice Address - Street 2:
Practice Address - City:HORSESHOE BEND
Practice Address - State:AR
Practice Address - Zip Code:72512-3110
Practice Address - Country:US
Practice Address - Phone:870-750-0694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-14
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist