Provider Demographics
NPI:1922466291
Name:MILES, TYNEESHA
Entity Type:Individual
Prefix:
First Name:TYNEESHA
Middle Name:
Last Name:MILES
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 1:14533 SANDY TRCE
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35405-7305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3701 LOOP RD
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404-5015
Practice Address - Country:US
Practice Address - Phone:205-554-3728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2-067161164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse