Healthcare Provider Details

I. General information

NPI: 1770937781
Provider Name (Legal Business Name): TANYA LYNN VELISHEK MSN, RN, PHN, PNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2016
Last Update Date: 04/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2535 UNIVERSITY AVE SE
MINNEAPOLIS MN
55414-3205
US

IV. Provider business mailing address

845 HICKORY PL
JORDAN MN
55352-1858
US

V. Phone/Fax

Practice location:
  • Phone: 612-672-2350
  • Fax:
Mailing address:
  • Phone: 612-275-4416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberCNP 4496
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: