Provider Demographics
NPI:1093555187
Name:JERALD, TYRA LOVELL
Entity type:Individual
Prefix:MISS
First Name:TYRA
Middle Name:LOVELL
Last Name:JERALD
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 1:4320 MANCHESTER LN
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28360-9001
Mailing Address - Country:US
Mailing Address - Phone:910-674-2621
Mailing Address - Fax:
Practice Address - Street 1:4320 MANCHESTER LN
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28360-9001
Practice Address - Country:US
Practice Address - Phone:910-674-2621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-28
Last Update Date:2024-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program