Provider Demographics
NPI:1598204729
Name:SCULLARK, MIA
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:SCULLARK
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 1:8809 FOREST BREEZE DR
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-7692
Mailing Address - Country:US
Mailing Address - Phone:901-691-6274
Mailing Address - Fax:
Practice Address - Street 1:8809 FOREST BREEZE DR
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-7692
Practice Address - Country:US
Practice Address - Phone:901-691-6274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide