Provider Demographics
NPI:1760287072
Name:LEE, TYRA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:TYRA
Middle Name:
Last Name:LEE
Suffix:
Gender:
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 1:148 W 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07203-1942
Mailing Address - Country:US
Mailing Address - Phone:732-598-3254
Mailing Address - Fax:
Practice Address - Street 1:55 WILLOW LN
Practice Address - Street 2:
Practice Address - City:ENGLISHTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07726-8434
Practice Address - Country:US
Practice Address - Phone:732-612-9833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ15119100363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily