Healthcare Provider Details

I. General information

NPI: 1457172595
Provider Name (Legal Business Name): TYLER NELLIS CPED4584
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2024
Last Update Date: 10/22/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9810 COUNTY ROAD D
BRUSSELS WI
54204-9511
US

IV. Provider business mailing address

9810 CTY RD D
BRUSSELS WI
54204
US

V. Phone/Fax

Practice location:
  • Phone: 920-445-5515
  • Fax:
Mailing address:
  • Phone: 920-445-5515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224L00000X
TaxonomyPedorthist
License NumberCPED4584
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: