Provider Demographics
NPI:1306162649
Name:BURNS, TINETRA EVETT-TAYLOR (MS, RSST, CAC-M)
Entity type:Individual
Prefix:MRS
First Name:TINETRA
Middle Name:EVETT-TAYLOR
Last Name:BURNS
Suffix:
Gender:F
Credentials:MS, RSST, CAC-M
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3850 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ECORSE
Mailing Address - State:MI
Mailing Address - Zip Code:48229-1319
Mailing Address - Country:US
Mailing Address - Phone:313-693-2141
Mailing Address - Fax:
Practice Address - Street 1:3850 12TH STREET
Practice Address - Street 2:
Practice Address - City:ECORSE
Practice Address - State:MI
Practice Address - Zip Code:48229-1319
Practice Address - Country:US
Practice Address - Phone:313-693-2141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-12
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803085412171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor