Healthcare Provider Details

I. General information

NPI: 1124939970
Provider Name (Legal Business Name): TIRSHA MAISHA WHEATLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2026
Last Update Date: 09/12/2026
Certification Date: 09/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 BENDING CREEK RD
ROCHESTER NY
14624-2134
US

IV. Provider business mailing address

30 BENDING CREEK RD
ROCHESTER NY
14624-2134
US

V. Phone/Fax

Practice location:
  • Phone: 347-909-3790
  • Fax:
Mailing address:
  • Phone: 347-909-3790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number796789
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: