Provider Demographics
NPI:1841064342
Name:KINGCANNON, TIA
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:KINGCANNON
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 1:2633 MCKINNEY AVE # 130124
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-2581
Mailing Address - Country:US
Mailing Address - Phone:469-535-1965
Mailing Address - Fax:
Practice Address - Street 1:3662 W CAMP WISDOM RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-2500
Practice Address - Country:US
Practice Address - Phone:469-535-1965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle