Provider Demographics
NPI:1821820606
Name:HODGES, TIELISHA CHAVANNES (OWNER)
Entity type:Individual
Prefix:
First Name:TIELISHA
Middle Name:CHAVANNES
Last Name:HODGES
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:TIELISHAS ALL
Other - Middle Name:PURPOSE
Other - Last Name:TRANSPORTATION
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4608 N 18TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-6429
Mailing Address - Country:US
Mailing Address - Phone:414-975-5106
Mailing Address - Fax:
Practice Address - Street 1:4608 N 18TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-6429
Practice Address - Country:US
Practice Address - Phone:414-975-5106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIH3228038264807342000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes342000000XTransportation ServicesTransportation Network Company