Provider Demographics
NPI:1649921610
Name:WEST, TANASHA KEONNA
Entity type:Individual
Prefix:
First Name:TANASHA
Middle Name:KEONNA
Last Name:WEST
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 1:2990 TARA DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1467
Mailing Address - Country:US
Mailing Address - Phone:770-545-9681
Mailing Address - Fax:
Practice Address - Street 1:2990 TARA DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1467
Practice Address - Country:US
Practice Address - Phone:770-545-9681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor