Provider Demographics
NPI:1851958078
Name:BAKER, TANYA (FNP)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5372 SPRUCEVIEW LN
Mailing Address - Street 2:
Mailing Address - City:FOWLERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48836-9654
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6020 W PIERSON RD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:MI
Practice Address - Zip Code:48433-2335
Practice Address - Country:US
Practice Address - Phone:810-720-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2021-05-24
Deactivation Date:2020-11-17
Deactivation Code:
Reactivation Date:2021-04-07
Provider Licenses
StateLicense IDTaxonomies
MIF03190799363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily