Provider Demographics
NPI:1649699554
Name:GREGORY, TA-TANISHIA
Entity type:Individual
Prefix:MRS
First Name:TA-TANISHIA
Middle Name:
Last Name:GREGORY
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 1:16008 DAMON AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-1453
Mailing Address - Country:US
Mailing Address - Phone:216-832-7158
Mailing Address - Fax:
Practice Address - Street 1:16008 DAMON AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110-1453
Practice Address - Country:US
Practice Address - Phone:216-832-7158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-08
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.371724163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH163W00000XMedicaid