Healthcare Provider Details

I. General information

NPI: 1386264687
Provider Name (Legal Business Name): TENA PAYTON-VANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2020
Last Update Date: 04/16/2020
Certification Date: 04/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39079 BUCKINGHAM DR
ROMULUS MI
48174-6325
US

IV. Provider business mailing address

39079 BUCKINGHAM DR
ROMULUS MI
48174-6325
US

V. Phone/Fax

Practice location:
  • Phone: 734-892-4744
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TENA PAYTON-VANCE
Title or Position: NP
Credential:
Phone: 734-892-4744