Provider Demographics
NPI:1265887939
Name:CLEMONS, TATISHA
Entity type:Individual
Prefix:
First Name:TATISHA
Middle Name:
Last Name:CLEMONS
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 1:10507 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-2527
Mailing Address - Country:US
Mailing Address - Phone:773-425-4702
Mailing Address - Fax:773-634-8092
Practice Address - Street 1:10507 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-2527
Practice Address - Country:US
Practice Address - Phone:773-425-4702
Practice Address - Fax:773-634-8092
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-29
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7666510Medicaid