Provider Demographics
NPI:1679206189
Name:BURRISON, TYNIKO VICTORIA
Entity Type:Individual
Prefix:
First Name:TYNIKO
Middle Name:VICTORIA
Last Name:BURRISON
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 1:126 WALDEN CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-6711
Mailing Address - Country:US
Mailing Address - Phone:803-454-5765
Mailing Address - Fax:
Practice Address - Street 1:126 WALDEN CREEK WAY
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6711
Practice Address - Country:US
Practice Address - Phone:803-454-5765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-03
Last Update Date:2022-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor