Healthcare Provider Details

I. General information

NPI: 1316698624
Provider Name (Legal Business Name): TYRA NOELL PEONE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2022
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9259 W STONEHAM DR
BOISE ID
83714-6705
US

IV. Provider business mailing address

9259 W STONEHAM DR
BOISE ID
83714-6705
US

V. Phone/Fax

Practice location:
  • Phone: 917-727-0486
  • Fax:
Mailing address:
  • Phone: 917-727-0486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL17498
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8911149
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: