Provider Demographics
NPI:1992419873
Name:SEALES, TANISHA LORAINE RAQUEL
Entity type:Individual
Prefix:
First Name:TANISHA
Middle Name:LORAINE RAQUEL
Last Name:SEALES
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 1:9548 E BRAMBLE AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85208-2659
Mailing Address - Country:US
Mailing Address - Phone:602-679-2477
Mailing Address - Fax:480-549-3916
Practice Address - Street 1:9548 E BRAMBLE AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85208-2659
Practice Address - Country:US
Practice Address - Phone:602-679-2477
Practice Address - Fax:480-549-3916
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-06
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZW12955932OtherNON MEDICAL HOME CARE
AZ185809Medicaid