Healthcare Provider Details

I. General information

NPI: 1881311363
Provider Name (Legal Business Name): KERRIANNA CAITLYN TYSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2022
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1887 SE PORT ST LUCIE BLVD
PORT SAINT LUCIE FL
34952-5530
US

IV. Provider business mailing address

998 NIXON CIR NE
PALM BAY FL
32907-1446
US

V. Phone/Fax

Practice location:
  • Phone: 722-463-0444
  • Fax: 772-219-1339
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: