Healthcare Provider Details

I. General information

NPI: 1487195392
Provider Name (Legal Business Name): CHARLOTTE TYSON REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2017
Last Update Date: 03/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 GRIDER ST
BUFFALO NY
14215-3021
US

IV. Provider business mailing address

462 GRIDER ST
BUFFALO NY
14215-3021
US

V. Phone/Fax

Practice location:
  • Phone: 716-898-1334
  • Fax: 716-898-1313
Mailing address:
  • Phone: 716-898-1334
  • Fax: 716-898-1313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number163WP0809X
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number386724
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: