Provider Demographics
NPI:1700969680
Name:MINYARD, TENNI MYNETTE (MD)
Entity Type:Individual
Prefix:
First Name:TENNI
Middle Name:MYNETTE
Last Name:MINYARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MYNETTE
Other - Middle Name:M
Other - Last Name:FOLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:FRUITA
Mailing Address - State:CO
Mailing Address - Zip Code:81521-0130
Mailing Address - Country:US
Mailing Address - Phone:970-858-2186
Mailing Address - Fax:970-858-2208
Practice Address - Street 1:281 N PLUM ST
Practice Address - Street 2:
Practice Address - City:FRUITA
Practice Address - State:CO
Practice Address - Zip Code:81521-2100
Practice Address - Country:US
Practice Address - Phone:970-858-9894
Practice Address - Fax:970-858-1331
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0036351207Q00000X
CO36351207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO58170871Medicaid
COG96751Medicare UPIN
COG96751Medicare UPIN