Provider Demographics
NPI:1518438332
Name:TANNER, TYWANNA R (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:TYWANNA
Middle Name:R
Last Name:TANNER
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1448
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-7248
Mailing Address - Country:US
Mailing Address - Phone:313-974-9487
Mailing Address - Fax:
Practice Address - Street 1:1158 FORT ST
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-1840
Practice Address - Country:US
Practice Address - Phone:313-989-0124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-06
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP3300X
MI4704264238363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain