Provider Demographics
NPI:1104326644
Name:BAILEY, TYSHIEKA Y (MD 442469)
Entity type:Individual
Prefix:MS
First Name:TYSHIEKA
Middle Name:Y
Last Name:BAILEY
Suffix:
Gender:F
Credentials:MD 442469
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-3234
Mailing Address - Country:US
Mailing Address - Phone:704-920-0234
Mailing Address - Fax:
Practice Address - Street 1:2051 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-3234
Practice Address - Country:US
Practice Address - Phone:410-353-0816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-20
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD332B00000X, 335E00000X
MD44224691744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier