Provider Demographics
NPI:1992201800
Name:TATUM, RENIECE LARUE
Entity Type:Individual
Prefix:
First Name:RENIECE
Middle Name:LARUE
Last Name:TATUM
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 1:1358 TERRIER DR APT F
Mailing Address - Street 2:
Mailing Address - City:COPLEY
Mailing Address - State:OH
Mailing Address - Zip Code:44321-2160
Mailing Address - Country:US
Mailing Address - Phone:330-396-1072
Mailing Address - Fax:
Practice Address - Street 1:404 STORER AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-2013
Practice Address - Country:US
Practice Address - Phone:330-864-0228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-01
Last Update Date:2018-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH085956174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist