Provider Demographics
NPI:1912378191
Name:TYESIA DENNIS
Entity Type:Organization
Organization Name:TYESIA DENNIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYESIA
Authorized Official - Middle Name:SHAKIMA
Authorized Official - Last Name:DENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-343-6349
Mailing Address - Street 1:6155 LONGCHAMP DR APT D
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-5141
Mailing Address - Country:US
Mailing Address - Phone:904-343-6349
Mailing Address - Fax:
Practice Address - Street 1:6155 LONGCHAMP DR APT D
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244-5141
Practice Address - Country:US
Practice Address - Phone:904-343-6349
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health