Provider Demographics
NPI:1881274199
Name:FETHERSON, TIARA (CERTIFIED HAIR LOSS)
Entity type:Individual
Prefix:
First Name:TIARA
Middle Name:
Last Name:FETHERSON
Suffix:
Gender:F
Credentials:CERTIFIED HAIR LOSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2516 REYNOLDA RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-4618
Mailing Address - Country:US
Mailing Address - Phone:980-230-4841
Mailing Address - Fax:
Practice Address - Street 1:2516 REYNOLDA RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-4618
Practice Address - Country:US
Practice Address - Phone:980-230-4841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-11
Last Update Date:2021-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC920971744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management