Healthcare Provider Details

I. General information

NPI: 1235869819
Provider Name (Legal Business Name): TINA SEXTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 N MAYO TRL
PAINTSVILLE KY
41240-1823
US

IV. Provider business mailing address

470 N MAYO TRL
PAINTSVILLE KY
41240-1823
US

V. Phone/Fax

Practice location:
  • Phone: 606-788-7275
  • Fax: 606-788-7342
Mailing address:
  • Phone: 606-788-7275
  • Fax: 606-788-7342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number110316
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: