Provider Demographics
NPI:1538638564
Name:CROCENZI, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:CROCENZI
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 1:38770 GARFIELD RD
Mailing Address - Street 2:STE 102
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6631
Mailing Address - Country:US
Mailing Address - Phone:586-421-4204
Mailing Address - Fax:586-421-4222
Practice Address - Street 1:38770 GARFIELD RD
Practice Address - Street 2:STE 102
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-6631
Practice Address - Country:US
Practice Address - Phone:586-421-4204
Practice Address - Fax:586-421-4222
Is Sole Proprietor?:No
Enumeration Date:2018-11-20
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAG11180011363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner