Provider Demographics
NPI:1407646631
Name:RAINEY, IDRISSA TYISHA EMILY
Entity type:Individual
Prefix:
First Name:IDRISSA
Middle Name:TYISHA EMILY
Last Name:RAINEY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 OXFORD ST APT 2B
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-5732
Mailing Address - Country:US
Mailing Address - Phone:862-220-6559
Mailing Address - Fax:
Practice Address - Street 1:9 OXFORD ST APT 2B
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-5732
Practice Address - Country:US
Practice Address - Phone:862-220-6559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-09
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula