Provider Demographics
NPI:1457045296
Name:WHITE, TYRA D
Entity Type:Individual
Prefix:
First Name:TYRA
Middle Name:D
Last Name:WHITE
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 1:10780 N PRESERVE WAY APT 103
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-6576
Mailing Address - Country:US
Mailing Address - Phone:786-907-6598
Mailing Address - Fax:
Practice Address - Street 1:10780 N PRESERVE WAY APT 103
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-6576
Practice Address - Country:US
Practice Address - Phone:786-907-6598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier