Healthcare Provider Details

I. General information

NPI: 1104005560
Provider Name (Legal Business Name): TAMI NYSSE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TAMI WITTINGEN

II. Dates (important events)

Enumeration Date: 11/01/2007
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 WILSON AVE NW
WALKER MI
49534-6404
US

IV. Provider business mailing address

1900 44TH ST SE
KENTWOOD MI
49508-5008
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-8650
  • Fax: 616-791-2160
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704228710
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704228710
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: