Healthcare Provider Details

I. General information

NPI: 1962035964
Provider Name (Legal Business Name): TYLER TRENTON WANSLEY DNP, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2020
Last Update Date: 04/29/2020
Certification Date: 04/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23515 US-190
MANDEVILLE LA
70448
US

IV. Provider business mailing address

23515 HIGHWAY 190
MANDEVILLE LA
70448-7334
US

V. Phone/Fax

Practice location:
  • Phone: 985-626-6300
  • Fax:
Mailing address:
  • Phone: 985-626-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number211117
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: