Provider Demographics
NPI:1417448432
Name:ANDERSON, TYRA LOUISE
Entity Type:Individual
Prefix:
First Name:TYRA
Middle Name:LOUISE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:858 AMBERWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30297-4256
Mailing Address - Country:US
Mailing Address - Phone:770-256-7221
Mailing Address - Fax:
Practice Address - Street 1:1514 CLEVELAND AVE STE 103-5
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-6965
Practice Address - Country:US
Practice Address - Phone:770-256-7221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-24
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1744P3200X174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA825455207OtherDEPARTMENT OF TREASURY INTERNAL REVENUE SERVICE