MEDICARE: JENNIFER R TYSON NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	0024190467	VA

General Provider Information

NPI Number	:	1134964307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER R TYSON NP

Provider Business Mailing Address
First Line	:	PO BOX 1599
Second Line	:
City	:	KILMARNOCK
State	:	VA
Zip	:	22482-1599
Country	:	US
Telephone Number	:	804-435-3103
Fax Number	:	804-435-6695

Provider Business Practice Location Address
First Line	:	107 DMV DR
Second Line	:
City	:	KILMARNOCK
State	:	VA
Zip	:	22482-3843
Country	:	US
Telephone Number	:	804-435-3103
Fax Number	:	804-435-6695

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2024
Last Update Date	:	06/28/2024

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