Provider Demographics
NPI:1407149420
Name:TOMMY, MINI M (NP)
Entity Type:Individual
Prefix:MRS
First Name:MINI
Middle Name:M
Last Name:TOMMY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:MINI
Other - Middle Name:MARY
Other - Last Name:MATHEWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4967 CROOKS RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-5801
Mailing Address - Country:US
Mailing Address - Phone:248-952-1601
Mailing Address - Fax:248-952-1614
Practice Address - Street 1:4967 CROOKS RD
Practice Address - Street 2:SUITE 130
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-5801
Practice Address - Country:US
Practice Address - Phone:248-952-1601
Practice Address - Fax:248-952-1614
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-24
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704204835363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily