Provider Demographics
NPI:1720857485
Name:HERDER-DUNCAN, TYNISHA DUSHUN (RN)
Entity Type:Individual
Prefix:
First Name:TYNISHA
Middle Name:DUSHUN
Last Name:HERDER-DUNCAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 DANIEL DR
Mailing Address - Street 2:
Mailing Address - City:DRESHER
Mailing Address - State:PA
Mailing Address - Zip Code:19025-1125
Mailing Address - Country:US
Mailing Address - Phone:215-237-9486
Mailing Address - Fax:
Practice Address - Street 1:1023 DANIEL DR
Practice Address - Street 2:
Practice Address - City:DRESHER
Practice Address - State:PA
Practice Address - Zip Code:19025-1125
Practice Address - Country:US
Practice Address - Phone:215-406-7848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-22
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X
PAPA-NH007914376G00000X
PARN556108163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No171400000XOther Service ProvidersHealth & Wellness Coach
No376G00000XNursing Service Related ProvidersNursing Home Administrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1041364520-0001Medicaid