Provider Demographics
NPI:1952995995
Name:REECE, TINA MARIE
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:REECE
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 1:4601 MAYFIELD DR
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-3955
Mailing Address - Country:US
Mailing Address - Phone:317-614-5177
Mailing Address - Fax:
Practice Address - Street 1:750 PARK EAST BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-0788
Practice Address - Country:US
Practice Address - Phone:765-447-7878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-21
Last Update Date:2021-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist