Provider Demographics
NPI:1194267682
Name:TYLER, DENISE
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:TYLER
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 1:7919 FAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19150-2103
Mailing Address - Country:US
Mailing Address - Phone:267-402-0108
Mailing Address - Fax:
Practice Address - Street 1:7919 FAYETTE ST
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19150-2103
Practice Address - Country:US
Practice Address - Phone:267-402-0108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAJI112924P6305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization