Provider Demographics
NPI:1205516754
Name:DEESE, TAHEISHA RENA (NP)
Entity type:Individual
Prefix:
First Name:TAHEISHA
Middle Name:RENA
Last Name:DEESE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 BUCKEYE LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1702
Mailing Address - Country:US
Mailing Address - Phone:229-425-8130
Mailing Address - Fax:
Practice Address - Street 1:1265 HIGHWAY 54 W STE 305
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4537
Practice Address - Country:US
Practice Address - Phone:770-719-5660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-20
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN165350208600000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No208600000XAllopathic & Osteopathic PhysiciansSurgery