Basic Information
| Provider Information | |||||||||
| NPI: | 1801336771 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLAYTON | ||||||||
| FirstName: | TIARRA | ||||||||
| MiddleName: | DANEESE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 CORPORATE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705083870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008939698 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5001 HARDY STREET | ||||||||
| Address2: | MERIT HEALTH WESLEY | ||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012963963 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2017 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 324143 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.