Provider Demographics
NPI:1164679510
Name:TYRA, VICTORIA LYNN (RN, FNP-C)
Entity type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:LYNN
Last Name:TYRA
Suffix:
Gender:F
Credentials:RN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1713 SONNET DR
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-2706
Mailing Address - Country:US
Mailing Address - Phone:972-977-9421
Mailing Address - Fax:
Practice Address - Street 1:N61W23044 HARRYS WAY
Practice Address - Street 2:
Practice Address - City:SUSSEX
Practice Address - State:WI
Practice Address - Zip Code:53089-3995
Practice Address - Country:US
Practice Address - Phone:866-275-3737
Practice Address - Fax:414-566-7613
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIAPNP9249363LF0000X
IN71009011B363LF0000X
NM64317363LF0000X
MS903244363LF0000X
VA0024181497363LF0000X
OH0030325363LF0000X
NYF349235-01363LF0000X
CA95025997363LF0000X
TXAP117203363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX308376801Medicaid