Provider Demographics
NPI:1336886167
Name:TWILLIE, TADERIA J
Entity Type:Individual
Prefix:
First Name:TADERIA
Middle Name:J
Last Name:TWILLIE
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 1:8845 LEZLARKEN LN
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-6875
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8845 LEZLARKEN LN
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-6875
Practice Address - Country:US
Practice Address - Phone:662-812-9378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-13
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program