Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0005X | Nurse Practitioner - Neonatal (Critical Care) | AP07691 | LA |
NPI | 1164846838 |
---|---|
Provider Name | Jennifer Tyson |
First Address | Baton Rouge, LA 70816-6038 |
Second Address | Alexandria, LA 71301-8124 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/02/2014 |
Last Update Date | 16/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
044440 | STATE NARCOTICS LICENSE (01) | LA |
2433725 | (05) | LA |
AP07691 | STATE LICENSE (01) | LA |
MT3166902 | DEA (01) | LA |