Provider Demographics
NPI:1831126192
Name:HARBISON, TONYA (CRNP)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:
Last Name:HARBISON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 MAIDEN CHOICE LN
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-5968
Mailing Address - Country:US
Mailing Address - Phone:313-582-2769
Mailing Address - Fax:313-846-7708
Practice Address - Street 1:15101 FORD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-4611
Practice Address - Country:US
Practice Address - Phone:313-582-2769
Practice Address - Fax:313-846-7708
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704101776363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
5008665410OtherBCBS OF MI
8304953OtherEVERCARE
MI1831126192Medicaid
M99950011Medicare PIN
P05294Medicare UPIN
0M99960Medicare PIN
MI1831126192Medicaid