Provider Demographics
NPI:1174000905
Name:HART, TYRA LYNN (MA60864479)
Entity Type:Individual
Prefix:
First Name:TYRA
Middle Name:LYNN
Last Name:HART
Suffix:
Gender:F
Credentials:MA60864479
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5805 60TH ST W
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98467-2831
Mailing Address - Country:US
Mailing Address - Phone:253-961-7344
Mailing Address - Fax:
Practice Address - Street 1:5805 60TH ST W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98467-2831
Practice Address - Country:US
Practice Address - Phone:253-961-7344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60864479225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist