Healthcare Provider Details

I. General information

NPI: 1447739081
Provider Name (Legal Business Name): TYNEKIA MARIE FRAZIER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2018
Last Update Date: 08/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 EAST RD APT 9
SAREPTA LA
71071-2465
US

IV. Provider business mailing address

2210 LINE AVE STE 207
SHREVEPORT LA
71104-2134
US

V. Phone/Fax

Practice location:
  • Phone: 318-639-1426
  • Fax:
Mailing address:
  • Phone: 318-675-1112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: