Provider Demographics
NPI:1336799246
Name:RICHARDSON, TIESHQUANNA CIARE
Entity type:Individual
Prefix:
First Name:TIESHQUANNA
Middle Name:CIARE
Last Name:RICHARDSON
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:PO BOX 94
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27528-0094
Mailing Address - Country:US
Mailing Address - Phone:919-809-0852
Mailing Address - Fax:844-246-5039
Practice Address - Street 1:312 KILGO ST
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-1651
Practice Address - Country:US
Practice Address - Phone:919-809-0852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-13
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC343900000X, 310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)