Provider Demographics
NPI:1073623708
Name:OWENS, TYNISA
Entity Type:Individual
Prefix:MRS
First Name:TYNISA
Middle Name:
Last Name:OWENS
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 1:1108 KEATS DR
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-8123
Mailing Address - Country:US
Mailing Address - Phone:469-371-3531
Mailing Address - Fax:
Practice Address - Street 1:3107 W CAMP WISDOM RD
Practice Address - Street 2:STE 950
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-2643
Practice Address - Country:US
Practice Address - Phone:214-339-4533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1163219OtherLICENSE #