Healthcare Provider Details

I. General information

NPI: 1508703943
Provider Name (Legal Business Name): TAHLEEF YASMEEN FITZGERALD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 E NORMAN AVE APT 4
DAYTON OH
45405-3513
US

IV. Provider business mailing address

108 E NORMAN AVE APT 4
DAYTON OH
45405-3513
US

V. Phone/Fax

Practice location:
  • Phone: 614-207-2419
  • Fax:
Mailing address:
  • Phone: 614-207-2419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberPRS.007730
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: