Provider Demographics
NPI:1699140889
Name:TYE, TATIANNA
Entity type:Individual
Prefix:
First Name:TATIANNA
Middle Name:
Last Name:TYE
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 1:25535 CATALINA ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-1774
Mailing Address - Country:US
Mailing Address - Phone:248-416-7425
Mailing Address - Fax:
Practice Address - Street 1:25535 CATALINA ST
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-1774
Practice Address - Country:US
Practice Address - Phone:248-416-7425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-14
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703115643164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse