Provider Demographics
NPI:1962090928
Name:LANKFORD, TINA
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:LANKFORD
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 1:613 SPICE ST
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-1482
Mailing Address - Country:US
Mailing Address - Phone:972-880-6172
Mailing Address - Fax:
Practice Address - Street 1:502 N HAMPTON RD STE C
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-4963
Practice Address - Country:US
Practice Address - Phone:469-297-4256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1635676332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition