Basic Information
| Provider Information | |||||||||
| NPI: | 1295491629 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIPPS | ||||||||
| FirstName: | KANESHA | ||||||||
| MiddleName: | MICHELE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4200 SUMNER RIDGE LN APT 1D | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274068351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045724076 | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 E WENDOVER AVE | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368323150 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2021 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.