Provider Demographics
NPI:1205466729
Name:STALLWORTH, TIMARA KEIANA
Entity type:Individual
Prefix:
First Name:TIMARA
Middle Name:KEIANA
Last Name:STALLWORTH
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 1:814 DONALD ST
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36617-2924
Mailing Address - Country:US
Mailing Address - Phone:404-857-9880
Mailing Address - Fax:
Practice Address - Street 1:814 DONALD ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36617-2924
Practice Address - Country:US
Practice Address - Phone:404-857-9880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS12715390200000X
GAPHI-020748390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program