Provider Demographics
NPI:1457879694
Name:STARKS, TELEIGHA TEILON LOURELL
Entity Type:Individual
Prefix:
First Name:TELEIGHA
Middle Name:TEILON LOURELL
Last Name:STARKS
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 1:629 SOUTH JOHNSON
Mailing Address - Street 2:3
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240
Mailing Address - Country:US
Mailing Address - Phone:319-621-9125
Mailing Address - Fax:
Practice Address - Street 1:629 SOUTH JOHNSON
Practice Address - Street 2:3
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240
Practice Address - Country:US
Practice Address - Phone:319-621-9125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA$$$$$$$$$Medicaid