Provider Demographics
NPI:1407831985
Name:TYSON, JANE F (FNP)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:F
Last Name:TYSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 315
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:8040 WOLF RIVER BOULEVARD
Practice Address - Street 2:SUITE 200
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1775
Practice Address - Country:US
Practice Address - Phone:901-726-0200
Practice Address - Fax:901-278-3050
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN92484363LF0000X, 363LF0000X
TNANCC-2004003633-22363LF0000X
TNAPN0000006702363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN620560967OtherTAX ID #MEDICAL GROUP
TNS30586Medicare UPIN
TN3648526Medicare ID - Type Unspecified