Provider Demographics
NPI:1912241886
Name:TYSON, SHELOME (FNP)
Entity type:Individual
Prefix:
First Name:SHELOME
Middle Name:
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 1:13101 227TH ST
Mailing Address - Street 2:
Mailing Address - City:LAURELTON
Mailing Address - State:NY
Mailing Address - Zip Code:11413-1738
Mailing Address - Country:US
Mailing Address - Phone:914-513-9657
Mailing Address - Fax:
Practice Address - Street 1:8900 VAN WYCK EXPY
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-2897
Practice Address - Country:US
Practice Address - Phone:718-206-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-16
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY654160163W00000X
NYF347436-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse