Healthcare Provider Details

I. General information

NPI: 1740540863
Provider Name (Legal Business Name): AUDREY J TYLER NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 05/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 VARICK ST
NEW YORK NY
10014-4810
US

IV. Provider business mailing address

1218 E 98TH ST
BROOKLYN NY
11236-4402
US

V. Phone/Fax

Practice location:
  • Phone: 212-620-0340
  • Fax: 212-243-4868
Mailing address:
  • Phone: 917-445-9524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF305729-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberF340822-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: