Provider Demographics
NPI:1205683000
Name:BOYD, TYEISHA M
Entity type:Individual
Prefix:
First Name:TYEISHA
Middle Name:M
Last Name:BOYD
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 1:621 S 20TH ST
Mailing Address - Street 2:UNIT 2
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103
Mailing Address - Country:US
Mailing Address - Phone:862-202-9909
Mailing Address - Fax:
Practice Address - Street 1:621 S 20TH ST
Practice Address - Street 2:UNIT 2
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103
Practice Address - Country:US
Practice Address - Phone:862-202-9909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver