Healthcare Provider Details

I. General information

NPI: 1013265966
Provider Name (Legal Business Name): TAHNEE SIEWERT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 08/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 S 41ST ST
MANITOWOC WI
54220-7316
US

IV. Provider business mailing address

4540 S 16TH ST
SHEBOYGAN WI
53081-7718
US

V. Phone/Fax

Practice location:
  • Phone: 920-320-4660
  • Fax:
Mailing address:
  • Phone: 920-634-9393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number5173-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number175038-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: