MEDICARE: MRS. TYKE CHERYLLYNN HANISCH RN, MS, FNP-C

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	363LP2300X	Primary Care Nurse Practitioner		AZ

General Provider Information

NPI Number	:	1326101932
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TYKE CHERYLLYNN HANISCH RN, MS, FNP-C

Provider Business Mailing Address
First Line	:	2322 S ROGERS
Second Line	:	UNIT # 11
City	:	MESA
State	:	AZ
Zip	:	85202-6562
Country	:	US
Telephone Number	:	480-839-4486
Fax Number	:	480-839-4486

Provider Business Practice Location Address
First Line	:	2150 E ORANGE ST
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85281-4814
Country	:	US
Telephone Number	:	480-350-5878
Fax Number	:	480-350-5865

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

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	07/08/2007

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