Provider Demographics
NPI:1669777363
Name:ANDERSON, TINA MAY (LPN)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MAY
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2631 MOUNT PLEASANT ST NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44721-1546
Mailing Address - Country:US
Mailing Address - Phone:330-232-5277
Mailing Address - Fax:
Practice Address - Street 1:2631 MOUNT PLEASANT ST NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44721-1546
Practice Address - Country:US
Practice Address - Phone:330-232-5277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.110987164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse