Provider Demographics
NPI:1154494623
Name:TYSON, JESSIE MICHELLE (RN)
Entity Type:Individual
Prefix:MS
First Name:JESSIE
Middle Name:MICHELLE
Last Name:TYSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28716-4822
Mailing Address - Country:US
Mailing Address - Phone:828-778-2048
Mailing Address - Fax:
Practice Address - Street 1:35 WOODFIN ST
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-3020
Practice Address - Country:US
Practice Address - Phone:828-250-5000
Practice Address - Fax:828-250-6165
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC146666163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC146666OtherR.N. LICENSE NUMBER