Provider Demographics
NPI:1740756881
Name:RICHARDS, TIARA SHAWNTE
Entity type:Individual
Prefix:
First Name:TIARA
Middle Name:SHAWNTE
Last Name:RICHARDS
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 1:1119 GINSBERG DR
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2421
Mailing Address - Country:US
Mailing Address - Phone:386-682-1559
Mailing Address - Fax:
Practice Address - Street 1:646 LPGA BLVD UNIT A
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:FL
Practice Address - Zip Code:32117-3108
Practice Address - Country:US
Practice Address - Phone:386-682-1559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant