Provider Demographics
NPI:1093337958
Name:TYSON, RASHEDA JUANDRELL
Entity type:Individual
Prefix:
First Name:RASHEDA
Middle Name:JUANDRELL
Last Name:TYSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2702 MASSACHUSETTS AVE APT 185
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32505-3475
Mailing Address - Country:US
Mailing Address - Phone:850-382-7803
Mailing Address - Fax:
Practice Address - Street 1:2702 MASSACHUSETTS AVE APT 185
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32505-3475
Practice Address - Country:US
Practice Address - Phone:850-382-7803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCL12755931744P3200X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
0827OtherNONE