Healthcare Provider Details

I. General information

NPI: 1073187209
Provider Name (Legal Business Name): MRS. TAMIKA HALL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

561 S PARK AVE
BUFFALO NY
14204-2627
US

IV. Provider business mailing address

561 S PARK AVE
BUFFALO NY
14204-2658
US

V. Phone/Fax

Practice location:
  • Phone: 716-465-9703
  • Fax:
Mailing address:
  • Phone: 716-465-9703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number357369
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number032121
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: