MEDICARE: BRENDA JO MCCLELLAN-TILSON APNP, MSN

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	75722-030	WI
2	363LW0102X	Women's Health Nurse Practitioner	789-33	WI

General Provider Information

NPI Number	:	1528189578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA JO MCCLELLAN-TILSON APNP, MSN

Provider Business Mailing Address
First Line	:	302 N JACKSON ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53202-5904
Country	:	US
Telephone Number	:	715-423-9610
Fax Number	:	715-423-7753

Provider Business Practice Location Address
First Line	:	1355 8TH ST S
Second Line	:
City	:	WISCONSIN RAPIDS
State	:	WI
Zip	:	54494-5265
Country	:	US
Telephone Number	:	715-423-9610
Fax Number	:	715-423-7753

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

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	08/19/2013

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