Provider Demographics
NPI:1235964347
Name:MARSHALL, TYRA DESHAWN (LPN)
Entity type:Individual
Prefix:
First Name:TYRA
Middle Name:DESHAWN
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 MIDVALE TER
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14619-2118
Mailing Address - Country:US
Mailing Address - Phone:585-760-9672
Mailing Address - Fax:
Practice Address - Street 1:106 MIDVALE TER
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14619-2118
Practice Address - Country:US
Practice Address - Phone:585-760-9672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY340362164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse