Healthcare Provider Details

I. General information

NPI: 1124023197
Provider Name (Legal Business Name): ALLEN TYLER NANCE P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6510 HIGHWAY 90 STE D
GAUTIER MS
39553-5015
US

IV. Provider business mailing address

PO BOX 200880
DALLAS TX
75320-0880
US

V. Phone/Fax

Practice location:
  • Phone: 228-875-7259
  • Fax: 228-438-2038
Mailing address:
  • Phone: 678-837-7176
  • Fax: 404-777-1311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number00004730
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number00004730
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: