Provider Demographics
NPI:1598593717
Name:MULLGRAV, TYASIA DANIELLE
Entity type:Individual
Prefix:
First Name:TYASIA
Middle Name:DANIELLE
Last Name:MULLGRAV
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 1:16335 130TH AVE APT 2E
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-3010
Mailing Address - Country:US
Mailing Address - Phone:718-612-3169
Mailing Address - Fax:
Practice Address - Street 1:300 COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3816
Practice Address - Country:US
Practice Address - Phone:516-562-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY826499163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency