MEDICARE: TYANNA CONNOR RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	4704247965	MI

General Provider Information

NPI Number	:	1164003554
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYANNA CONNOR RN

Provider Business Mailing Address
First Line	:	2710 WOLCOTT ST
Second Line	:
City	:	FLINT
State	:	MI
Zip	:	48504-3357
Country	:	US
Telephone Number	:	810-210-8123
Fax Number	:

Provider Business Practice Location Address
First Line	:	2710 WOLCOTT ST
Second Line	:
City	:	FLINT
State	:	MI
Zip	:	48504-3357
Country	:	US
Telephone Number	:	810-210-8123
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/16/2021
Last Update Date	:	04/16/2021

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