=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083501571
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYLER ROBERT NIEVES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2025
-----------------------------------------------------
Last Update Date | 07/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10818 FRUITLAND DR
-----------------------------------------------------
City | STUDIO CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91604-3508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-216-2059
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10818 FRUITLAND DR
-----------------------------------------------------
City | STUDIO CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91604-3508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-216-2059
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 95036313
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 95115411
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------