Provider Demographics
NPI:1841740206
Name:KING, TIA DENAE (NP-C)
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:DENAE
Last Name:KING
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 MARTIN LUTHER KING JR DR SW
Mailing Address - Street 2:SUITE 206
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30311-1636
Mailing Address - Country:US
Mailing Address - Phone:404-691-4321
Mailing Address - Fax:404-691-4304
Practice Address - Street 1:2600 MARTIN LUTHER KING JR DR SW
Practice Address - Street 2:SUITE 206
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30311-1636
Practice Address - Country:US
Practice Address - Phone:404-691-4321
Practice Address - Fax:404-691-4304
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN200247363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner