Provider Demographics
NPI:1639515570
Name:STEVENS, TYISHA
Entity Type:Individual
Prefix:
First Name:TYISHA
Middle Name:
Last Name:STEVENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:YAA
Other - Middle Name:NEFERMUL
Other - Last Name:MAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1877 BROAD ST
Mailing Address - Street 2:FLOOR 3
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06114-1710
Mailing Address - Country:US
Mailing Address - Phone:860-578-4325
Mailing Address - Fax:
Practice Address - Street 1:1877 BROAD ST
Practice Address - Street 2:FLOOR 3
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06114-1710
Practice Address - Country:US
Practice Address - Phone:860-578-4325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-19
Last Update Date:2013-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula