=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346641644
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRANT P TYLER NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2014
-----------------------------------------------------
Last Update Date | 08/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 311 S COUNTY FARM RD
-----------------------------------------------------
City | WHEATON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60187-2477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-755-5264
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 311 S COUNTY FARM RD STE A
-----------------------------------------------------
City | WHEATON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60187-2477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-755-5264
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 71005249A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 209027126
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------