Healthcare Provider Details

I. General information

NPI: 1083501571
Provider Name (Legal Business Name): TYLER ROBERT NIEVES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2025
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 E BROADWAY STE 314
LONG BEACH CA
90802-7801
US

IV. Provider business mailing address

5783 FOOTHILL DR
LOS ANGELES CA
90068-3653
US

V. Phone/Fax

Practice location:
  • Phone: 888-588-8995
  • Fax:
Mailing address:
  • Phone: 719-216-2059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95036313
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95115411
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: