Healthcare Provider Details

I. General information

NPI: 1699594804
Provider Name (Legal Business Name): TATSIANA LIMTIACO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2024
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7149 BLACKSHIP RUN RD FORT CAMPBELL, KY
APO AP
37040
US

IV. Provider business mailing address

650 JOEL DR
FORT CAMPBELL KY
42223-5318
US

V. Phone/Fax

Practice location:
  • Phone: 270-798-5931
  • Fax:
Mailing address:
  • Phone: 270-798-5931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number113746
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: