Healthcare Provider Details

I. General information

NPI: 1598414849
Provider Name (Legal Business Name): DEYANNIRA TIRADO APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2022
Last Update Date: 09/28/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 ROANOKE BLVD
SALEM VA
24153
US

IV. Provider business mailing address

82 RAVINE RIDGE DR S
POWELL OH
43065-8926
US

V. Phone/Fax

Practice location:
  • Phone: 540-982-2463
  • Fax:
Mailing address:
  • Phone: 941-962-6207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.485620
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN.CNP.0032093
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: