Provider Demographics
NPI:1679745699
Name:GARVIN, TJADA S
Entity type:Individual
Prefix:MRS
First Name:TJADA
Middle Name:S
Last Name:GARVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:TJADA
Other - Middle Name:S
Other - Last Name:GARVIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:18 NORWOOD PL
Mailing Address - Street 2:
Mailing Address - City:WYANDANCH
Mailing Address - State:NY
Mailing Address - Zip Code:11798-1029
Mailing Address - Country:US
Mailing Address - Phone:631-805-6956
Mailing Address - Fax:
Practice Address - Street 1:18 NORWOOD PL
Practice Address - Street 2:
Practice Address - City:WYANDANCH
Practice Address - State:NY
Practice Address - Zip Code:11798-1029
Practice Address - Country:US
Practice Address - Phone:631-805-6956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-31
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF311885363L00000X
NY578008163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse