Provider Demographics
NPI:1639588189
Name:NYLAND, TYFFANY
Entity Type:Individual
Prefix:
First Name:TYFFANY
Middle Name:
Last Name:NYLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2709 WATER RIDGE PKWY STE 500
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-4592
Mailing Address - Country:US
Mailing Address - Phone:855-438-0010
Mailing Address - Fax:
Practice Address - Street 1:2709 WATER RIDGE PKWY STE 500
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217
Practice Address - Country:US
Practice Address - Phone:855-438-0010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-08
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5007049363L00000X
NC247701363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1639588189Medicaid
SCNP3402Medicaid
SCNP3402Medicaid
NCNCL1110386Medicare PIN
NCNCL111BMedicare PIN
NC1639588189Medicaid
NCNCL111CMedicare PIN
NCNCL111EMedicare PIN