Provider Demographics
NPI:1790814036
Name:TYLER, JEANNINE CAMILLE (BS)
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:CAMILLE
Last Name:TYLER
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 NW 47TH ST
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064-5005
Mailing Address - Country:US
Mailing Address - Phone:954-258-9300
Mailing Address - Fax:
Practice Address - Street 1:2900 W PROSPECT RD
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-2519
Practice Address - Country:US
Practice Address - Phone:954-677-3113
Practice Address - Fax:954-497-3857
Is Sole Proprietor?:No
Enumeration Date:2007-03-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator