Provider Demographics
NPI:1013263896
Name:ETAYEM, TINA GAYLE (LPN)
Entity Type:Individual
Prefix:MISS
First Name:TINA
Middle Name:GAYLE
Last Name:ETAYEM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:TINA
Other - Middle Name:GAYLE
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1736 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-4508
Mailing Address - Country:US
Mailing Address - Phone:937-831-3874
Mailing Address - Fax:
Practice Address - Street 1:1736 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-4508
Practice Address - Country:US
Practice Address - Phone:937-831-3874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 074282 MEDS164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse