=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851367114
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CORNELIUS REGINA TYLER FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2006
-----------------------------------------------------
Last Update Date | 01/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 W HOSPITAL RD
-----------------------------------------------------
City | FORT EISENHOWER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30905-5741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-787-5811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3507 MONROE CT
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30909-9243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-339-1183
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | RN320315
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 4304P
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------