Provider Demographics
NPI:1225530249
Name:EICKHOLT, TYLER ANNE (RN, PHN)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:ANNE
Last Name:EICKHOLT
Suffix:
Gender:F
Credentials:RN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4333 SWIFT AVE APT 1/2
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-6613
Mailing Address - Country:US
Mailing Address - Phone:484-995-9885
Mailing Address - Fax:
Practice Address - Street 1:367 N MAGNOLIA AVE STE 101
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-3995
Practice Address - Country:US
Practice Address - Phone:619-441-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95113008163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse