Provider Demographics
NPI:1114349735
Name:BECKETT, TYSAM (APRN, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:TYSAM
Middle Name:
Last Name:BECKETT
Suffix:
Gender:F
Credentials:APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10821 FOXHOLE RD
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-8013
Mailing Address - Country:US
Mailing Address - Phone:407-408-4433
Mailing Address - Fax:
Practice Address - Street 1:10821 FOXHOLE RD
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-8013
Practice Address - Country:US
Practice Address - Phone:407-408-4433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-16
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9368798163WP0808X
FLAPRN11014430363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health