Healthcare Provider Details

I. General information

NPI: 1063639086
Provider Name (Legal Business Name): CHAUNETTA CECILIA TYREE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2429 LINDEN AVE 2ND FLOOR
BALTIMORE MD
21217-4540
US

IV. Provider business mailing address

2429 LINDEN AVE 2ND FLOOR
BALTIMORE MD
21217-4540
US

V. Phone/Fax

Practice location:
  • Phone: 410-669-0522
  • Fax:
Mailing address:
  • Phone: 410-669-0522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberA00016799
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: