Provider Demographics
NPI:1518600360
Name:TYSON, FABIOLA (FNP-C)
Entity Type:Individual
Prefix:
First Name:FABIOLA
Middle Name:
Last Name:TYSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 CHAPARRAL DR
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-6115
Mailing Address - Country:US
Mailing Address - Phone:760-790-7665
Mailing Address - Fax:
Practice Address - Street 1:2026 N IMPERIAL AVE STE C
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-1607
Practice Address - Country:US
Practice Address - Phone:760-592-4351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95020675363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily