MEDICARE: TYRA TATUM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	42743	TX

General Provider Information

NPI Number	:	1144945304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYRA TATUM

Provider Business Mailing Address
First Line	:	PO BOX 1049
Second Line	:
City	:	ORE CITY
State	:	TX
Zip	:	75683-1049
Country	:	US
Telephone Number	:	469-435-1094
Fax Number	:

Provider Business Practice Location Address
First Line	:	6466 RIDGECREST RD APT 2126
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75231-6979
Country	:	US
Telephone Number	:	469-435-1094
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2022
Last Update Date	:	10/10/2022

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Directions to “ TYRA TATUM ” Practice Location

Language	Start Address	Practice Location

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