Healthcare Provider Details

I. General information

NPI: 1336902485
Provider Name (Legal Business Name): TAMARA BREHM BURKHALTER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2024
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 GREEN BAY RD
NORTH CHICAGO IL
60064-3048
US

IV. Provider business mailing address

3001 GREEN BAY RD
NORTH CHICAGO IL
60064-3048
US

V. Phone/Fax

Practice location:
  • Phone: 563-581-5868
  • Fax:
Mailing address:
  • Phone: 563-581-5868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number111600
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: