Provider Demographics
NPI:1821862327
Name:WOLVERTON, TYESHA
Entity Type:Individual
Prefix:MRS
First Name:TYESHA
Middle Name:
Last Name:WOLVERTON
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 1:1035 SUSIE B RUFFIN AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-3082
Mailing Address - Country:US
Mailing Address - Phone:601-689-4443
Mailing Address - Fax:
Practice Address - Street 1:1035 SUSIE B RUFFIN AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-3082
Practice Address - Country:US
Practice Address - Phone:601-689-4443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide