Healthcare Provider Details

I. General information

NPI: 1609204585
Provider Name (Legal Business Name): CHARLEY TYRE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2013
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2627 WINDING CV
GRIMESLAND NC
27837-8612
US

IV. Provider business mailing address

PO BOX 333
MANNS HARBOR NC
27953-0333
US

V. Phone/Fax

Practice location:
  • Phone: 252-217-8288
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number5006569
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: