=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700404845
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. TYRONIA PATRICIA PORCHIA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2020
-----------------------------------------------------
Last Update Date | 07/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8911 RAMONA AVE
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63121-4018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-261-3949
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8911 RAMONA AVE # 89
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63121-4018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-261-3949
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number | LC9927162
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------