MEDICARE: MISS LOREN ANNE RAY TYSON NURSE PRACTITIONER

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	363LA2200X	Adult Health Nurse Practitioner	0024170891	VA
2	363L00000X	Nurse Practitioner	0024170891	VA
3	363LA2200X	Adult Health Nurse Practitioner	26NJ00060800	NJ

General Provider Information

NPI Number	:	1295724276
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS LOREN ANNE RAY TYSON NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	10527 REEDS LANDING CIR
Second Line	:
City	:	BURKE
State	:	VA
Zip	:	22015-2513
Country	:	US
Telephone Number	:	201-232-5162
Fax Number	:	703-289-4612

Provider Business Practice Location Address
First Line	:	8280 WILLOW OAKS CORPORATE DR STE 100
Second Line	:
City	:	FAIRFAX
State	:	VA
Zip	:	22031-4517
Country	:	US
Telephone Number	:	703-269-3270
Fax Number	:	703-269-3271

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

Provider Enumeration Date	:	10/21/2005
Last Update Date	:	04/03/2026

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