Healthcare Provider Details

I. General information

NPI: 1093340630
Provider Name (Legal Business Name): TARA BETH TYE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WILLIAM NORTHERN BLVD
TULLAHOMA TN
37388-4754
US

IV. Provider business mailing address

739 BRANDONTOWN RD
MANCHESTER TN
37355-7623
US

V. Phone/Fax

Practice location:
  • Phone: 931-454-0489
  • Fax: 931-454-1227
Mailing address:
  • Phone: 931-581-4025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number27241
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: