Provider Demographics
NPI:1285668178
Name:TYNER, AMY C (MA CCC SLP)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:C
Last Name:TYNER
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 LAKELAND HIGHLANDS RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-4338
Mailing Address - Country:US
Mailing Address - Phone:863-686-3189
Mailing Address - Fax:863-682-1348
Practice Address - Street 1:3020 LAKELAND HIGHLANDS RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4338
Practice Address - Country:US
Practice Address - Phone:863-686-3189
Practice Address - Fax:863-682-1348
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA3653235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS2869OtherBLUE CROSS BLUE SHIELD
FL883059200Medicaid
FL672202496OtherMEDWAIVER
FL244OtherATA
FL113991OtherAMERIGROUP
FL11982201OtherCITRUS HEALTHCARE