Healthcare Provider Details

I. General information

NPI: 1457107773
Provider Name (Legal Business Name): DAWN RENE TYE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2024
Last Update Date: 04/26/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 MILKY WAY RD
BRUCEVILLE TX
76630-3450
US

IV. Provider business mailing address

131 MILKY WAY RD
BRUCEVILLE TX
76630-3450
US

V. Phone/Fax

Practice location:
  • Phone: 912-544-8541
  • Fax:
Mailing address:
  • Phone: 254-485-4191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2021358
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: