Provider Demographics
NPI:1891498655
Name:LAURY, TIVERA
Entity Type:Individual
Prefix:
First Name:TIVERA
Middle Name:
Last Name:LAURY
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 1:3503 CORUM DR APT 1126
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23294-8948
Mailing Address - Country:US
Mailing Address - Phone:804-688-0397
Mailing Address - Fax:
Practice Address - Street 1:500 CRESCENT CREEK LN
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76140-6589
Practice Address - Country:US
Practice Address - Phone:804-688-0397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001299230163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse