Healthcare Provider Details

I. General information

NPI: 1891616173
Provider Name (Legal Business Name): TYRA ANN-MARIE WILKINS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 STRATHMORE COURT DR
CORAM NY
11727-1605
US

IV. Provider business mailing address

100 STRATHMORE COURT DR
CORAM NY
11727-1605
US

V. Phone/Fax

Practice location:
  • Phone: 631-294-9562
  • Fax:
Mailing address:
  • Phone: 631-294-9562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number353500-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: