Healthcare Provider Details

I. General information

NPI: 1043847346
Provider Name (Legal Business Name): TYLER OWEN PICKENS RN, BSN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 03/25/2020
Certification Date: 03/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MAIN ST
CHATTAHOOCHEE FL
32324-1107
US

IV. Provider business mailing address

957 HAYWOOD DR
CHIPLEY FL
32428-2184
US

V. Phone/Fax

Practice location:
  • Phone: 850-663-7905
  • Fax: 850-663-7897
Mailing address:
  • Phone: 850-209-2437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN9392671
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN9392671
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: