Provider Demographics
NPI:1740540863
Name:TYLER, AUDREY J (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:J
Last Name:TYLER
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 E 98TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4402
Mailing Address - Country:US
Mailing Address - Phone:917-445-9524
Mailing Address - Fax:
Practice Address - Street 1:200 VARICK ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10014-4810
Practice Address - Country:US
Practice Address - Phone:212-620-0340
Practice Address - Fax:212-243-4868
Is Sole Proprietor?:No
Enumeration Date:2012-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF305729-1363LA2200X
NYF340822-1363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology