Provider Demographics
NPI:1073154365
Name:TYLER, TRACY DAWN
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:DAWN
Last Name:TYLER
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 1:5455 FIELDFREEN DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30028-3898
Mailing Address - Country:US
Mailing Address - Phone:404-427-4723
Mailing Address - Fax:
Practice Address - Street 1:11111 HOUZE RD STE 225
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5618
Practice Address - Country:US
Practice Address - Phone:770-603-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN239833363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health