Provider Demographics
NPI:1932489960
Name:KING, TYISHA SHAQUANA (LPN)
Entity Type:Individual
Prefix:
First Name:TYISHA
Middle Name:SHAQUANA
Last Name:KING
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 DENIS LN
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-1513
Mailing Address - Country:US
Mailing Address - Phone:631-388-2478
Mailing Address - Fax:
Practice Address - Street 1:19 DENIS LN
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-1513
Practice Address - Country:US
Practice Address - Phone:631-388-2478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-22
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY296660164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse