Healthcare Provider Details

I. General information

NPI: 1871666404
Provider Name (Legal Business Name): CHRISTINA DANIELS TYLER NPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHRISTINA DANIELS TYLER FNP-C

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3755 SIXES RD SUITE 100
CANTON GA
30114
US

IV. Provider business mailing address

3755 SIXES RD SUITE 100
CANTON GA
30114-7842
US

V. Phone/Fax

Practice location:
  • Phone: 770-704-4580
  • Fax: 770-704-9142
Mailing address:
  • Phone: 770-704-4580
  • Fax: 770-704-9142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRN153645NP
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN153645NP
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: