Provider Demographics
NPI:1528804739
Name:JANNONE, TYLER JAMES
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:JAMES
Last Name:JANNONE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:839 W UNION ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:PA
Mailing Address - Zip Code:17724-7463
Mailing Address - Country:US
Mailing Address - Phone:570-916-2699
Mailing Address - Fax:
Practice Address - Street 1:401 N FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:LOCK HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17745-2390
Practice Address - Country:US
Practice Address - Phone:570-484-2027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-08
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA261QH0100X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer