Provider Demographics
NPI:1053984583
Name:STEPHENS, TIERRA
Entity type:Individual
Prefix:
First Name:TIERRA
Middle Name:
Last Name:STEPHENS
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 1:583 OLD JACKSON RD APT 1315
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-0515
Mailing Address - Country:US
Mailing Address - Phone:769-237-0443
Mailing Address - Fax:
Practice Address - Street 1:720 HARBOUR POINTE XING STE 303
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-1152
Practice Address - Country:US
Practice Address - Phone:601-301-9912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier