Provider Demographics
NPI:1447747175
Name:ROSE, TYRA ALLYCE (RN)
Entity Type:Individual
Prefix:
First Name:TYRA
Middle Name:ALLYCE
Last Name:ROSE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5412 LAUSTIN LN
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76543-4341
Mailing Address - Country:US
Mailing Address - Phone:254-226-4059
Mailing Address - Fax:
Practice Address - Street 1:5412 LAUSTIN LN
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-4341
Practice Address - Country:US
Practice Address - Phone:254-226-4059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX858307163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse