Provider Demographics
NPI:1609533041
Name:KING, TYESIA ANDRETTE (SPECIMEN COLLECTOR)
Entity Type:Individual
Prefix:
First Name:TYESIA
Middle Name:ANDRETTE
Last Name:KING
Suffix:
Gender:F
Credentials:SPECIMEN COLLECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 N MILLER ST APT 47
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:GA
Mailing Address - Zip Code:31539-6818
Mailing Address - Country:US
Mailing Address - Phone:912-347-2737
Mailing Address - Fax:
Practice Address - Street 1:153 N MILLER ST APT 47
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:GA
Practice Address - Zip Code:31539-6818
Practice Address - Country:US
Practice Address - Phone:912-347-2737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty