Provider Demographics
NPI:1265930333
Name:HURSEY, TIARRA
Entity type:Individual
Prefix:
First Name:TIARRA
Middle Name:
Last Name:HURSEY
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 1:3701 WOODHAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21216-1520
Mailing Address - Country:US
Mailing Address - Phone:410-240-7586
Mailing Address - Fax:
Practice Address - Street 1:3701 WOODHAVEN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-1520
Practice Address - Country:US
Practice Address - Phone:410-240-7586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD82-4068616310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility