Healthcare Provider Details

I. General information

NPI: 1790268209
Provider Name (Legal Business Name): IVY NICOLE TUELLER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 NW 11TH ST STE M206
HERMISTON OR
97838-6941
US

IV. Provider business mailing address

620 NW 11TH ST STE M206
HERMISTON OR
97838-6941
US

V. Phone/Fax

Practice location:
  • Phone: 541-667-3804
  • Fax: 541-667-0192
Mailing address:
  • Phone: 541-667-3804
  • Fax: 541-667-0192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number022776
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA218318
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: