Provider Demographics
NPI:1609476464
Name:LIGHTNER, TEAIRA LEE
Entity Type:Individual
Prefix:MS
First Name:TEAIRA
Middle Name:LEE
Last Name:LIGHTNER
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 1:515 19TH ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44709-3874
Mailing Address - Country:US
Mailing Address - Phone:234-244-7757
Mailing Address - Fax:
Practice Address - Street 1:515 19TH ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44709-3874
Practice Address - Country:US
Practice Address - Phone:234-244-7757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0133406Medicaid