MEDICARE: YANNIQUE TELLO CNM

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	367A00000X	Advanced Practice Midwife	RN216695	GA

General Provider Information

NPI Number	:	1881286185
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YANNIQUE TELLO CNM

Provider Business Mailing Address
First Line	:	PO BOX 962380
Second Line	:
City	:	RIVERDALE
State	:	GA
Zip	:	30296-6921
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	81 UPPER RIVERDALE RD SW STE 210
Second Line	:
City	:	RIVERDALE
State	:	GA
Zip	:	30274-2627
Country	:	US
Telephone Number	:	770-996-1200
Fax Number	:

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

Provider Enumeration Date	:	02/08/2021
Last Update Date	:	02/08/2021

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