Provider Demographics
NPI:1710412135
Name:TYYNISMAA, VERONICA A
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:A
Last Name:TYYNISMAA
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 1:6038 FARGO RD
Mailing Address - Street 2:
Mailing Address - City:CROSWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48422-8863
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5176 CUSTER RD
Practice Address - Street 2:
Practice Address - City:CARSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:48419-9744
Practice Address - Country:US
Practice Address - Phone:810-622-0341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI171M00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI$$$$$$$$$Medicaid
MI$$$$$$$$$Medicare PIN
MI$$$$$$$$$Medicaid
MI$$$$$$$$$Medicare Oscar/Certification