Provider Demographics
NPI:1396983227
Name:TYRE, MITZI BRADDOCK (FNP)
Entity type:Individual
Prefix:
First Name:MITZI
Middle Name:BRADDOCK
Last Name:TYRE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MITZ
Other - Middle Name:BRADDOCK
Other - Last Name:TYRE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:2900 MOSSY OAK TRL
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31503-4621
Mailing Address - Country:US
Mailing Address - Phone:912-387-7737
Mailing Address - Fax:
Practice Address - Street 1:1007 MARY ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31503-3823
Practice Address - Country:US
Practice Address - Phone:912-387-7737
Practice Address - Fax:912-449-7080
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-30
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN170702163W00000X, 363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily