Provider Demographics
NPI:1730642513
Name:STURDIVANT, TYLER LEE (MSN, RN, AGCNS-BC)
Entity type:Individual
Prefix:MR
First Name:TYLER
Middle Name:LEE
Last Name:STURDIVANT
Suffix:
Gender:M
Credentials:MSN, RN, AGCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3305 FRANKLIN CT
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36618-4275
Mailing Address - Country:US
Mailing Address - Phone:334-456-9747
Mailing Address - Fax:
Practice Address - Street 1:5721 USA DRIVE NORTH HAHN 4067
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36688-0001
Practice Address - Country:US
Practice Address - Phone:251-341-3007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-140692364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Single Specialty