Healthcare Provider Details

I. General information

NPI: 1891222808
Provider Name (Legal Business Name): TESS LACIE CURNYN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TESS LACIE EDVARDSEN DO

II. Dates (important events)

Enumeration Date: 05/22/2017
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52500 FIR RD
GRANGER IN
46530-8579
US

IV. Provider business mailing address

52500 FIR RD
GRANGER IN
46530-8579
US

V. Phone/Fax

Practice location:
  • Phone: 574-271-0700
  • Fax: 574-273-5648
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPENDING
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: