Provider Demographics
NPI:1699252536
Name:KEITH, TYNAE DOMINIQUE
Entity type:Individual
Prefix:
First Name:TYNAE
Middle Name:DOMINIQUE
Last Name:KEITH
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 1:5814 PINE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-1218
Mailing Address - Country:US
Mailing Address - Phone:267-504-2464
Mailing Address - Fax:267-292-4893
Practice Address - Street 1:5814 PINE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-1218
Practice Address - Country:US
Practice Address - Phone:267-504-2464
Practice Address - Fax:267-292-4893
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA37183601374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide