=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316754666
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYISHI JESSICA LAYNE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2024
-----------------------------------------------------
Last Update Date | 12/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 119 MAPLE AVE SE
-----------------------------------------------------
City | MASSILLON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44646-8066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 234-378-7920
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 119 MAPLE AVE SE
-----------------------------------------------------
City | MASSILLON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44646-8066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 234-378-7920
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364SH0200X
-----------------------------------------------------
Taxonomy Name | Home Health Clinical Nurse Specialist
-----------------------------------------------------
License Number | UA780040
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------