Provider Demographics
NPI:1164255121
Name:ANTHONY, TIA (NP)
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:ANTHONY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 CLARK RD
Mailing Address - Street 2:
Mailing Address - City:CRAWFORD
Mailing Address - State:MS
Mailing Address - Zip Code:39743-9472
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:79 CLARK RD
Practice Address - Street 2:
Practice Address - City:CRAWFORD
Practice Address - State:MS
Practice Address - Zip Code:39743-9472
Practice Address - Country:US
Practice Address - Phone:662-574-9799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-23
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906789363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner