Provider Demographics
NPI:1598184384
Name:HUMPHREYS, TIA (LPN)
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:HUMPHREYS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9207 SENECA TRL
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-1328
Mailing Address - Country:US
Mailing Address - Phone:304-645-1787
Mailing Address - Fax:304-645-3630
Practice Address - Street 1:9207 SENECA TRL
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-1328
Practice Address - Country:US
Practice Address - Phone:304-645-1787
Practice Address - Fax:304-645-3630
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24712164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse