Provider Demographics
NPI:1306820329
Name:TYNES, YOLANDA S (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:YOLANDA
Middle Name:S
Last Name:TYNES
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MRS
Other - First Name:SUSIE
Other - Middle Name:
Other - Last Name:TYNES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:907 OAK LEVEL RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-5391
Mailing Address - Country:US
Mailing Address - Phone:270-703-0390
Mailing Address - Fax:
Practice Address - Street 1:416 CENTRAL AVENUE
Practice Address - Street 2:GRAVES COUNTY HEALTH DEPARTMENT
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066
Practice Address - Country:US
Practice Address - Phone:270-247-3553
Practice Address - Fax:270-247-0392
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2145P363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY20079018Medicaid
KYS96408Medicare UPIN
KY20079018Medicaid