Provider Demographics
NPI:1972917730
Name:BOSTIC, TYNIKIA (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:TYNIKIA
Middle Name:
Last Name:BOSTIC
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:TYNIKIA
Other - Middle Name:
Other - Last Name:BOSTIC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PMHNP-BC
Mailing Address - Street 1:27300 LA ROSE DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-4423
Mailing Address - Country:US
Mailing Address - Phone:586-229-5571
Mailing Address - Fax:
Practice Address - Street 1:27300 LA ROSE DR
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-4423
Practice Address - Country:US
Practice Address - Phone:586-229-5571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703113511164W00000X
MI4704336140363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse