Healthcare Provider Details

I. General information

NPI: 1467229153
Provider Name (Legal Business Name): SHANNON E TYLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2023
Last Update Date: 12/04/2023
Certification Date: 12/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1681 BLANKENSHIP RD
GOODVIEW VA
24095-2729
US

IV. Provider business mailing address

1681 BLANKENSHIP RD
GOODVIEW VA
24095-2729
US

V. Phone/Fax

Practice location:
  • Phone: 540-521-7447
  • Fax:
Mailing address:
  • Phone: 540-521-7447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224ZE0001X
TaxonomyEnvironmental Modification Occupational Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: