Provider Demographics
NPI:1861018566
Name:PURYEAR, TSHAWNALYN ALIZE NICOLE
Entity Type:Individual
Prefix:
First Name:TSHAWNALYN
Middle Name:ALIZE NICOLE
Last Name:PURYEAR
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 1:6300 W TROPICANA AVE TRLR 159
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-4422
Mailing Address - Country:US
Mailing Address - Phone:702-881-7543
Mailing Address - Fax:
Practice Address - Street 1:6300 W TROPICANA AVE TRLR 159
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-4422
Practice Address - Country:US
Practice Address - Phone:702-881-7543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner