Provider Demographics
NPI:1780944538
Name:DIRVEN, TAMARA LYNN WYSCAVER (ACNP-BC)
Entity type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:LYNN WYSCAVER
Last Name:DIRVEN
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1524
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-1524
Mailing Address - Country:US
Mailing Address - Phone:706-774-8326
Mailing Address - Fax:706-774-7230
Practice Address - Street 1:3990 JOHN R ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2018
Practice Address - Country:US
Practice Address - Phone:313-993-6023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704193954363LA2100X
GARN287474363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care