Provider Demographics
NPI:1881311363
Name:TYSON, KERRIANNA CAITLYN
Entity type:Individual
Prefix:
First Name:KERRIANNA
Middle Name:CAITLYN
Last Name:TYSON
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 1:998 NIXON CIR NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-1446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1887 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5530
Practice Address - Country:US
Practice Address - Phone:722-463-0444
Practice Address - Fax:772-219-1339
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-25
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty