Provider Demographics
NPI:1184380776
Name:TYSON, DESZIREE
Entity type:Individual
Prefix:MS
First Name:DESZIREE
Middle Name:
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 1:4601 S 1ST ST APT 136
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-5902
Mailing Address - Country:US
Mailing Address - Phone:414-795-1329
Mailing Address - Fax:
Practice Address - Street 1:4601 S 1ST ST APT 136
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-5902
Practice Address - Country:US
Practice Address - Phone:414-795-1329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula