Provider Demographics
NPI:1437683224
Name:TYSON, STEPHANIE E (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:E
Last Name:TYSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:TARPLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1835 SAVOY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1071
Mailing Address - Country:US
Mailing Address - Phone:706-253-3100
Mailing Address - Fax:706-253-3101
Practice Address - Street 1:134 MOUNTAINSIDE VILLAGE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-8694
Practice Address - Country:US
Practice Address - Phone:706-253-3100
Practice Address - Fax:706-253-3101
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN200512363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003203586AMedicaid
GAG04354AOtherMEDICARE PTAN