Provider Demographics
NPI:1609156611
Name:NORTHUP, TINA GAIL (RNC-NIC)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:GAIL
Last Name:NORTHUP
Suffix:
Gender:F
Credentials:RNC-NIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:372 GENE GUNTER RD
Mailing Address - Street 2:
Mailing Address - City:DEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71328-9218
Mailing Address - Country:US
Mailing Address - Phone:318-466-9683
Mailing Address - Fax:
Practice Address - Street 1:372 GENE GUNTER RD
Practice Address - Street 2:
Practice Address - City:DEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71328-9218
Practice Address - Country:US
Practice Address - Phone:318-466-9683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-22
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN065622163WN0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care