Provider Demographics
NPI:1962058909
Name:MCGARRELL, TISHMA
Entity type:Individual
Prefix:
First Name:TISHMA
Middle Name:
Last Name:MCGARRELL
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 1:755 ANGE RD
Mailing Address - Street 2:
Mailing Address - City:GRIFTON
Mailing Address - State:NC
Mailing Address - Zip Code:28530-9036
Mailing Address - Country:US
Mailing Address - Phone:252-876-1176
Mailing Address - Fax:
Practice Address - Street 1:102 N B STREET
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:NC
Practice Address - Zip Code:28519-2851
Practice Address - Country:US
Practice Address - Phone:252-876-1176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC88088224P00000X
224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist