Provider Demographics
NPI:1689027757
Name:FLY, TINA
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:FLY
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 1:1016 W POPLAR AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-2687
Mailing Address - Country:US
Mailing Address - Phone:901-850-0811
Mailing Address - Fax:
Practice Address - Street 1:1016 W POPLAR AVE STE 112
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-2687
Practice Address - Country:US
Practice Address - Phone:901-850-0811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-13
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPO482156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician