Individual
TYRA LOUISE ANDERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1514 CLEVELAND AVE STE 103-5, EAST POINT, GA 30344-6965
(770) 256-7221
Mailing address
858 AMBERWOOD WAY, FOREST PARK, GA 30297-4256
(770) 256-7221
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
1744P3200X
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
825455207
DEPARTMENT OF TREASURY INTERNAL REVENUE SERVICE
GA
Enumeration date
05/24/2018
Last updated
06/16/2018
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