Provider Demographics
NPI:1649753468
Name:TYRIE, THERESA MONTGOMERY (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:MONTGOMERY
Last Name:TYRIE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MISS
Other - First Name:THERESA
Other - Middle Name:RENAE
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2021 N CROOKED BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34461-9453
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2021 N CROOKED BRANCH DR
Practice Address - Street 2:
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-9453
Practice Address - Country:US
Practice Address - Phone:352-436-4428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9293072363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health