Provider Demographics
NPI:1073841011
Name:PENN, TYNISE LA'SHAIE (NP)
Entity Type:Individual
Prefix:
First Name:TYNISE
Middle Name:LA'SHAIE
Last Name:PENN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TYNISE
Other - Middle Name:LA'SHAIE
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:31355 BRETZ DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-5532
Mailing Address - Country:US
Mailing Address - Phone:313-350-1657
Mailing Address - Fax:248-934-1390
Practice Address - Street 1:29877 TELEGRAPH RD STE 401
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-7661
Practice Address - Country:US
Practice Address - Phone:248-294-0539
Practice Address - Fax:248-934-1390
Is Sole Proprietor?:No
Enumeration Date:2009-12-03
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704240129363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H26358Medicare PIN