Individual
TYRA HAWTHORNE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
11464 NASHVILLE ST, DETROIT, MI 48205-3237
(313) 694-7290
Mailing address
11464 NASHVILLE ST, DETROIT, MI 48205-3237
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
4703122040
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
H365809485592
DRIVERS LICENSE
MI
Enumeration date
02/23/2023
Last updated
02/23/2023
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