Healthcare Provider Details

I. General information

NPI: 1720689920
Provider Name (Legal Business Name): TAMMY LYNN PROHOFSKY APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TAMMY PERTTULA APRN, CNP

II. Dates (important events)

Enumeration Date: 11/04/2020
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11000 OPTUM CIR
EDEN PRAIRIE MN
55344-2503
US

IV. Provider business mailing address

12490 FAIRBANKS AVE
LONSDALE MN
55046-4475
US

V. Phone/Fax

Practice location:
  • Phone: 866-686-2504
  • Fax:
Mailing address:
  • Phone: 763-257-9280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number7897
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR147035-4
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: