Provider Demographics
NPI:1104330885
Name:WILSON, TYNYEA N
Entity type:Individual
Prefix:
First Name:TYNYEA
Middle Name:N
Last Name:WILSON
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 1:5229 MARLBORO PIKE APT 104
Mailing Address - Street 2:
Mailing Address - City:CAPITOL HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20743-5427
Mailing Address - Country:US
Mailing Address - Phone:443-805-0550
Mailing Address - Fax:
Practice Address - Street 1:5229 MARLBORO PIKE APT 104
Practice Address - Street 2:
Practice Address - City:CAPITOL HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20743-5427
Practice Address - Country:US
Practice Address - Phone:443-805-0550
Practice Address - Fax:443-805-0550
Is Sole Proprietor?:No
Enumeration Date:2017-11-17
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDHHA13177374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide