Provider Demographics
NPI:1720782766
Name:GAITER, TYRA J
Entity Type:Individual
Prefix:
First Name:TYRA
Middle Name:J
Last Name:GAITER
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 1:4134 SPRINGBURN DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-6549
Mailing Address - Country:US
Mailing Address - Phone:419-936-8378
Mailing Address - Fax:
Practice Address - Street 1:4134 SPRINGBURN DR
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-6549
Practice Address - Country:US
Practice Address - Phone:419-936-8378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.171791.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse