Healthcare Provider Details

I. General information

NPI: 1003530098
Provider Name (Legal Business Name): TYNETTA QUNIQUE BEAMON-SIMPSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TYNETTA QUNIQUE SIMPSON APRN

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 08/26/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10710 OLD HIGHWAY 64
BOLIVAR TN
38008-3587
US

IV. Provider business mailing address

6628 CROSS OAK CV
MEMPHIS TN
38141-0400
US

V. Phone/Fax

Practice location:
  • Phone: 731-658-6113
  • Fax:
Mailing address:
  • Phone: 901-672-3109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number193503
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number32489
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: