MEDICARE: LEANNA M TYLER FNP

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	363LF0000X	Family Nurse Practitioner	AP09586	LA

General Provider Information

NPI Number	:	1285149401
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEANNA M TYLER FNP

Provider Business Mailing Address
First Line	:	1455 E BERT KOUNS INDUSTRIAL LOOP
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-5634
Country	:	US
Telephone Number	:	318-798-4488
Fax Number	:	318-798-4672

Provider Business Practice Location Address
First Line	:	5025 SHED RD
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-5434
Country	:	US
Telephone Number	:	318-798-4488
Fax Number	:	318-798-4672

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

Provider Enumeration Date	:	12/11/2017
Last Update Date	:	08/06/2021

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