Provider Demographics
NPI:1669012571
Name:TYLER-HENDERSON, SHANA MARIE (NP)
Entity Type:Individual
Prefix:MRS
First Name:SHANA
Middle Name:MARIE
Last Name:TYLER-HENDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39301 SHREE RD
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-7284
Mailing Address - Country:US
Mailing Address - Phone:858-232-1222
Mailing Address - Fax:
Practice Address - Street 1:39301 SHREE RD
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-7284
Practice Address - Country:US
Practice Address - Phone:858-232-1222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95013315363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily