Provider Demographics
NPI:1427626969
Name:TINNELL, THEODORE
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:TINNELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 N PEARL ST APT 605
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80203-4190
Mailing Address - Country:US
Mailing Address - Phone:303-809-1261
Mailing Address - Fax:
Practice Address - Street 1:130 N PEARL ST APT 605
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80203-4190
Practice Address - Country:US
Practice Address - Phone:303-809-1261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR245581163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice