Healthcare Provider Details

I. General information

NPI: 1528979408
Provider Name (Legal Business Name): TINICHIA STORY HUDSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 SPAULDING RD
MONTEZUMA GA
31063-1725
US

IV. Provider business mailing address

113 NORRIS ST
MONTEZUMA GA
31063-1416
US

V. Phone/Fax

Practice location:
  • Phone: 478-777-2984
  • Fax:
Mailing address:
  • Phone: 478-244-9098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN711260
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: