Provider Demographics
NPI:1891809901
Name:TYSON, COLLEEN R (FNP)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:R
Last Name:TYSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2157 COUNTY ROAD 220
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-9197
Mailing Address - Country:US
Mailing Address - Phone:307-630-5884
Mailing Address - Fax:
Practice Address - Street 1:2360 E PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5356
Practice Address - Country:US
Practice Address - Phone:307-778-7316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY11323.1067363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily