Provider Demographics
NPI:1427471309
Name:OLIVER, TYRI (LPN)
Entity type:Individual
Prefix:
First Name:TYRI
Middle Name:
Last Name:OLIVER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 572
Mailing Address - Street 2:
Mailing Address - City:BELLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11713-0572
Mailing Address - Country:US
Mailing Address - Phone:347-844-4004
Mailing Address - Fax:
Practice Address - Street 1:909 PROVOST AVENUE
Practice Address - Street 2:
Practice Address - City:BELLPORT
Practice Address - State:NY
Practice Address - Zip Code:11713-0572
Practice Address - Country:US
Practice Address - Phone:347-844-4004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY316490-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse