Provider Demographics
NPI:1295057644
Name:TYLER-JIMENEZ, ELIZABETH NICOLE
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:NICOLE
Last Name:TYLER-JIMENEZ
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 1:929 NW GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-4503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:929 NW GRANT AVE
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-4503
Practice Address - Country:US
Practice Address - Phone:541-754-1023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-25
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORBL100U3LMedicaid