Provider Demographics
NPI:1215688627
Name:TYNER, KACY JO GRIFFITH (CRNP)
Entity type:Individual
Prefix:
First Name:KACY
Middle Name:JO GRIFFITH
Last Name:TYNER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 BELCHER ST
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35042-2946
Mailing Address - Country:US
Mailing Address - Phone:205-926-2992
Mailing Address - Fax:205-316-7675
Practice Address - Street 1:873 DENNISON AVE SW STE 102
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35211-3867
Practice Address - Country:US
Practice Address - Phone:205-774-3309
Practice Address - Fax:205-316-7675
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-17
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-176450163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse