Provider Demographics
NPI:1265948673
Name:ACKERSON, TINA JOY (RN)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:JOY
Last Name:ACKERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:JOY
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8213 23RD PL NE
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-6419
Mailing Address - Country:US
Mailing Address - Phone:360-610-5864
Mailing Address - Fax:
Practice Address - Street 1:8213 23RD PL NE
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-6419
Practice Address - Country:US
Practice Address - Phone:360-610-5864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60201096163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse