Provider Demographics
NPI:1407396435
Name:SAYRE, TIESHA MAE (STNA)
Entity type:Individual
Prefix:
First Name:TIESHA
Middle Name:MAE
Last Name:SAYRE
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-2211
Mailing Address - Country:US
Mailing Address - Phone:330-281-8856
Mailing Address - Fax:
Practice Address - Street 1:235 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-2211
Practice Address - Country:US
Practice Address - Phone:330-281-8856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-23
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH320919530612172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker