Provider Demographics
NPI:1730565227
Name:TYSON, PHYLLIS (RN)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:TYSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1746 E SILVER STAR RD
Mailing Address - Street 2:107
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-7014
Mailing Address - Country:US
Mailing Address - Phone:407-925-7237
Mailing Address - Fax:407-445-4601
Practice Address - Street 1:7034 MINIPPI DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-3345
Practice Address - Country:US
Practice Address - Phone:407-925-7237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN2529832163WG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0600XNursing Service ProvidersRegistered NurseGerontology