Provider Demographics
NPI:1265907075
Name:HEATH, TISA
Entity type:Individual
Prefix:MS
First Name:TISA
Middle Name:
Last Name:HEATH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 CONLEY RD APT 100
Mailing Address - Street 2:
Mailing Address - City:CONLEY
Mailing Address - State:GA
Mailing Address - Zip Code:30288-1885
Mailing Address - Country:US
Mailing Address - Phone:404-387-3040
Mailing Address - Fax:
Practice Address - Street 1:2135 TIFFANY LN
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-5320
Practice Address - Country:US
Practice Address - Phone:678-984-4984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA81-4250548OtherTID