Healthcare Provider Details

I. General information

NPI: 1588292155
Provider Name (Legal Business Name): TANU KHURANA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4125 HARBOR TOWN LN
MANITOWOC WI
54220-5855
US

IV. Provider business mailing address

1614 HALSEY ST
GREEN BAY WI
54301-2418
US

V. Phone/Fax

Practice location:
  • Phone: 920-686-3200
  • Fax:
Mailing address:
  • Phone: 412-657-8966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1002331
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: