Provider Demographics
NPI:1578941811
Name:TYSON, MICHELE (ANP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:
Last Name:TYSON
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65742-9357
Mailing Address - Country:US
Mailing Address - Phone:417-753-9404
Mailing Address - Fax:417-753-9137
Practice Address - Street 1:101 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65742-9357
Practice Address - Country:US
Practice Address - Phone:417-753-9404
Practice Address - Fax:417-753-9137
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-06
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007020586163W00000X
MO2015013115363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse