Provider Demographics
NPI:1548834989
Name:AZURE, TINA M
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:AZURE
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:PO BOX 1909
Mailing Address - Street 2:
Mailing Address - City:BELCOURT
Mailing Address - State:ND
Mailing Address - Zip Code:58316-1909
Mailing Address - Country:US
Mailing Address - Phone:701-472-2394
Mailing Address - Fax:
Practice Address - Street 1:9959 BIA RD 25
Practice Address - Street 2:
Practice Address - City:DUNSEITH
Practice Address - State:ND
Practice Address - Zip Code:58329
Practice Address - Country:US
Practice Address - Phone:701-244-0693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1456575372500000X, 376J00000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No372500000XNursing Service Related ProvidersChore Provider
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1456575Medicaid