Provider Demographics
NPI:1053794644
Name:PERRY, TAWANDA
Entity type:Individual
Prefix:
First Name:TAWANDA
Middle Name:
Last Name:PERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18541 PLYMOUTH RD
Mailing Address - Street 2:APT 2
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-1170
Mailing Address - Country:US
Mailing Address - Phone:313-989-8658
Mailing Address - Fax:
Practice Address - Street 1:26648 RYAN RD
Practice Address - Street 2:APT B4
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-1146
Practice Address - Country:US
Practice Address - Phone:313-989-8658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIP60078522027172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker