Provider Demographics
NPI:1952960924
Name:TYSON, MIMI
Entity Type:Individual
Prefix:
First Name:MIMI
Middle Name:
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 1:4014 DIAMONDHEAD AVE
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-1308
Mailing Address - Country:US
Mailing Address - Phone:301-828-5239
Mailing Address - Fax:
Practice Address - Street 1:11810 GRAND PARK AVE STE 500
Practice Address - Street 2:
Practice Address - City:NORTH BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20852-8679
Practice Address - Country:US
Practice Address - Phone:030-139-2712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR180111363LP0808X
VA0024177697363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health