Provider Demographics
NPI:1912761859
Name:PHILLIPS, TIA TAQUESTA
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:TAQUESTA
Last Name:PHILLIPS
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 1:105 HOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-4607
Mailing Address - Country:US
Mailing Address - Phone:561-563-1973
Mailing Address - Fax:
Practice Address - Street 1:105 HOLLY AVE
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-4607
Practice Address - Country:US
Practice Address - Phone:561-563-1973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies