Healthcare Provider Details

I. General information

NPI: 1942723143
Provider Name (Legal Business Name): ELVIS TAMBI STARLLONE APRN, PMHNP-BC, CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2017
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 HAYWARD AVE N
OAKDALE MN
55128-7127
US

IV. Provider business mailing address

625 HAYWARD AVE N
OAKDALE MN
55128-7127
US

V. Phone/Fax

Practice location:
  • Phone: 651-410-7955
  • Fax:
Mailing address:
  • Phone: 651-410-7955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5270
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: