Provider Demographics
NPI:1861018988
Name:TERRELL, TYMBER TATUM (APRN)
Entity Type:Individual
Prefix:
First Name:TYMBER
Middle Name:TATUM
Last Name:TERRELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:TYMBER
Other - Middle Name:LEE
Other - Last Name:TATUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:2556 NW 216TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWTEY
Mailing Address - State:FL
Mailing Address - Zip Code:32058-4101
Mailing Address - Country:US
Mailing Address - Phone:386-247-1295
Mailing Address - Fax:
Practice Address - Street 1:2556 NW 216TH ST
Practice Address - Street 2:
Practice Address - City:LAWTEY
Practice Address - State:FL
Practice Address - Zip Code:32058-4101
Practice Address - Country:US
Practice Address - Phone:386-247-1295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-24
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11007399363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAPRN11007399OtherLICENSE