Provider Demographics
NPI:1700336765
Name:BYRD, TINA MARIE (LMP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:BYRD
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 VANDERCOOK WAY STE 5
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-4039
Mailing Address - Country:US
Mailing Address - Phone:360-200-2892
Mailing Address - Fax:
Practice Address - Street 1:803 VANDERCOOK WAY STE 5
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-4039
Practice Address - Country:US
Practice Address - Phone:360-200-2892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-13
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60681429172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker