Provider Demographics
NPI:1194996520
Name:FARRELL, TINA KAY
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:KAY
Last Name:FARRELL
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 1:4399 35TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33714-3722
Mailing Address - Country:US
Mailing Address - Phone:727-526-0501
Mailing Address - Fax:727-527-9695
Practice Address - Street 1:7400 GALL BLVD
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33541-4371
Practice Address - Country:US
Practice Address - Phone:813-782-4546
Practice Address - Fax:813-782-1902
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-13
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO 5179156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician