Provider Demographics
NPI:1174920847
Name:TAYLOR, TYRA LYNN (NP)
Entity type:Individual
Prefix:
First Name:TYRA
Middle Name:LYNN
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TYRA
Other - Middle Name:L
Other - Last Name:MASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:1201 FURMAN L FENDLEY HWY STE C
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:SC
Practice Address - Zip Code:29379-7419
Practice Address - Country:US
Practice Address - Phone:864-427-8380
Practice Address - Fax:864-427-8308
Is Sole Proprietor?:No
Enumeration Date:2014-11-24
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19181363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP3008Medicaid
SCNP3008Medicaid