Healthcare Provider Details

I. General information

NPI: 1073841011
Provider Name (Legal Business Name): TYNISE LA'SHAIE PENN N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TYNISE LA'SHAIE GRAY

II. Dates (important events)

Enumeration Date: 12/03/2009
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29877 TELEGRAPH RD STE 401
SOUTHFIELD MI
48034-7661
US

IV. Provider business mailing address

31355 BRETZ DR
WARREN MI
48093-5532
US

V. Phone/Fax

Practice location:
  • Phone: 248-294-0539
  • Fax: 248-934-1390
Mailing address:
  • Phone: 313-350-1657
  • Fax: 248-934-1390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704240129
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704240129
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: