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NPI Code Detail

MEDICARE: DIANE ELIZABETH TYLER

MEDICARE: DIANE ELIZABETH TYLER
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
1363L00000XNurse Practitioner8264MN
2363LP0808XPsychiatric/Mental Health Nurse Practitioner8264MN

General Provider Information

NPI Number : 1760150213
Entity Type Code : Individual
Provider Name (Legal Business Name) : DIANE ELIZABETH TYLER
Provider Business Mailing Address
First Line : 516 S POKEGAMA AVE
Second Line :
City : GRAND RAPIDS
State : MN
Zip : 55744-3820
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 516 S POKEGAMA AVE
Second Line :
City : GRAND RAPIDS
State : MN
Zip : 55744-3820
Country : US
Telephone Number : 218-327-2001
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/31/2021
Last Update Date : 08/31/2021

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