Provider Demographics
NPI:1205550019
Name:STEWART, TIARA MONET
Entity type:Individual
Prefix:
First Name:TIARA
Middle Name:MONET
Last Name:STEWART
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 1:3523 CONVERSE AVE
Mailing Address - Street 2:
Mailing Address - City:EAST ST LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62207
Mailing Address - Country:US
Mailing Address - Phone:618-477-7126
Mailing Address - Fax:
Practice Address - Street 1:3523 CONVERSE AVE
Practice Address - Street 2:
Practice Address - City:EAST ST LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62207
Practice Address - Country:US
Practice Address - Phone:618-477-7126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver