Provider Demographics
NPI:1285941641
Name:TYSON, VICTORIA KENNEDY (CRNP-PMH)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:KENNEDY
Last Name:TYSON
Suffix:
Gender:F
Credentials:CRNP-PMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21409-6309
Mailing Address - Country:US
Mailing Address - Phone:240-997-6124
Mailing Address - Fax:410-757-3343
Practice Address - Street 1:175 ADMIRAL COCHRANE DR STE 110
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401
Practice Address - Country:US
Practice Address - Phone:410-571-0888
Practice Address - Fax:410-571-0889
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR097928363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health