Healthcare Provider Details

I. General information

NPI: 1730565227
Provider Name (Legal Business Name): PHYLLIS TYSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2015
Last Update Date: 08/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7034 MINIPPI DR
ORLANDO FL
32818-3345
US

IV. Provider business mailing address

1746 E SILVER STAR RD 107
OCOEE FL
34761-7014
US

V. Phone/Fax

Practice location:
  • Phone: 407-925-7237
  • Fax:
Mailing address:
  • Phone: 407-925-7237
  • Fax: 407-445-4601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License NumberRN2529832
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: