Provider Demographics
NPI:1235898818
Name:STATE, TYLER ANDREW (LVN)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:ANDREW
Last Name:STATE
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60805 29 PALMS HWY
Mailing Address - Street 2:
Mailing Address - City:JOSHUA TREE
Mailing Address - State:CA
Mailing Address - Zip Code:92252-5901
Mailing Address - Country:US
Mailing Address - Phone:760-974-5990
Mailing Address - Fax:
Practice Address - Street 1:60805 29 PALMS HWY
Practice Address - Street 2:
Practice Address - City:JOSHUA TREE
Practice Address - State:CA
Practice Address - Zip Code:92252-5901
Practice Address - Country:US
Practice Address - Phone:760-974-5990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA287335164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse