Provider Demographics
NPI:1932768462
Name:CRUMBY, TIARA SADE
Entity Type:Individual
Prefix:
First Name:TIARA
Middle Name:SADE
Last Name:CRUMBY
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 1:5401 MALLARD DR S
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-3110
Mailing Address - Country:US
Mailing Address - Phone:704-449-5420
Mailing Address - Fax:
Practice Address - Street 1:5401 MALLARD DR S
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227-3110
Practice Address - Country:US
Practice Address - Phone:704-449-5420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-09
Last Update Date:2019-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide