Provider Demographics
NPI:1174804728
Name:JETER, TAMIKA ANDREA (LPN)
Entity type:Individual
Prefix:MS
First Name:TAMIKA
Middle Name:ANDREA
Last Name:JETER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 HIGHLAND ST
Mailing Address - Street 2:2ND FLR
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1622
Mailing Address - Country:US
Mailing Address - Phone:315-420-1748
Mailing Address - Fax:
Practice Address - Street 1:302 HIGHLAND ST
Practice Address - Street 2:2ND FLR
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1622
Practice Address - Country:US
Practice Address - Phone:315-420-1748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY273250164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse