Provider Demographics
NPI:1619968542
Name:TYREE, DALTREY ANNE (PMHNP, APRN)
Entity Type:Individual
Prefix:MRS
First Name:DALTREY
Middle Name:ANNE
Last Name:TYREE
Suffix:
Gender:F
Credentials:PMHNP, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911B SCOTTSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3303
Mailing Address - Country:US
Mailing Address - Phone:270-421-3397
Mailing Address - Fax:270-550-2008
Practice Address - Street 1:1911 B SCOTTSVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3303
Practice Address - Country:US
Practice Address - Phone:270-421-3397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4688P363L00000X
KY3004688363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100579550Medicaid
AZ554523Medicaid