Provider Demographics
NPI:1821164989
Name:SOUTHERN, TYE (RN)
Entity Type:Individual
Prefix:
First Name:TYE
Middle Name:
Last Name:SOUTHERN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2455 SE LARKSPUR CT
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-8332
Mailing Address - Country:US
Mailing Address - Phone:503-648-7148
Mailing Address - Fax:
Practice Address - Street 1:2455 SE LARKSPUR CT
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-8332
Practice Address - Country:US
Practice Address - Phone:503-648-7148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse