Provider Demographics
NPI:1770233736
Name:TYSON, ANITRA RANEE
Entity Type:Individual
Prefix:MS
First Name:ANITRA
Middle Name:RANEE
Last Name:TYSON
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 1:915 HAZEL ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-1613
Mailing Address - Country:US
Mailing Address - Phone:269-286-2725
Mailing Address - Fax:
Practice Address - Street 1:915 HAZEL ST
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-1613
Practice Address - Country:US
Practice Address - Phone:269-286-2725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health