Provider Demographics
NPI:1740945062
Name:KING, TINA MARIE
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:355 BLUEFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-2883
Mailing Address - Country:US
Mailing Address - Phone:304-425-7111
Mailing Address - Fax:304-425-1138
Practice Address - Street 1:355 BLUEFIELD AVE
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-2883
Practice Address - Country:US
Practice Address - Phone:304-425-7111
Practice Address - Fax:304-425-1138
Is Sole Proprietor?:No
Enumeration Date:2021-11-02
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1568796027376J00000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV55-6025355Medicaid