Healthcare Provider Details

I. General information

NPI: 1780344945
Provider Name (Legal Business Name): TYLER ANDREW LAVENDER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2021
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1890 SUMMIT BLVD # 240
PENSACOLA FL
32503-3357
US

IV. Provider business mailing address

24691 CHANTILLY LN
DAPHNE AL
36526-6293
US

V. Phone/Fax

Practice location:
  • Phone: 850-746-0600
  • Fax:
Mailing address:
  • Phone: 662-889-3980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License NumberOT21525
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: