Provider Demographics
NPI:1457705352
Name:PRICE, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:PRICE
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 1:1201 LODESTAR DR
Mailing Address - Street 2:
Mailing Address - City:HOLIDAY
Mailing Address - State:FL
Mailing Address - Zip Code:34690-6518
Mailing Address - Country:US
Mailing Address - Phone:727-614-2069
Mailing Address - Fax:727-940-3650
Practice Address - Street 1:1201 LODESTAR DR
Practice Address - Street 2:
Practice Address - City:HOLIDAY
Practice Address - State:FL
Practice Address - Zip Code:34690-6518
Practice Address - Country:US
Practice Address - Phone:727-614-2069
Practice Address - Fax:727-940-3650
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-17
Last Update Date:2016-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906848172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker