Provider Demographics
NPI:1093531105
Name:MERRELL, TIENNA T
Entity type:Individual
Prefix:
First Name:TIENNA
Middle Name:T
Last Name:MERRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12335 RIAD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-1576
Mailing Address - Country:US
Mailing Address - Phone:313-728-4799
Mailing Address - Fax:
Practice Address - Street 1:12335 RIAD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-1576
Practice Address - Country:US
Practice Address - Phone:313-728-4799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-23
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No174N00000XOther Service ProvidersLactation Consultant, Non-RN