Healthcare Provider Details

I. General information

NPI: 1144687047
Provider Name (Legal Business Name): TYISHA RENEE FLETCHER PMHNP - BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2016
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 E PACIFIC COAST HWY STE 320
LONG BEACH CA
90804-3271
US

IV. Provider business mailing address

4500 E PACIFIC COAST HWY STE 320
LONG BEACH CA
90804-3271
US

V. Phone/Fax

Practice location:
  • Phone: 925-282-1778
  • Fax: 415-296-5299
Mailing address:
  • Phone: 925-282-1778
  • Fax: 415-296-5299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95003663
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number95003663
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number822354
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1045983
License Number StateTX
# 5
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95003663
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: