Healthcare Provider Details

I. General information

NPI: 1215866256
Provider Name (Legal Business Name): TYSONS HEART IN HOME SUPPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18321 DEMOCRACY AVE
RUTHER GLEN VA
22546-2959
US

IV. Provider business mailing address

18321 DEMOCRACY AVE
RUTHER GLEN VA
22546-2959
US

V. Phone/Fax

Practice location:
  • Phone: 757-771-5171
  • Fax:
Mailing address:
  • Phone: 757-771-5171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. TRACY TRENAE TYSON
Title or Position: OWNER
Credential: TYSON
Phone: 757-771-5171