Healthcare Provider Details

I. General information

NPI: 1174830152
Provider Name (Legal Business Name): KELLY NICOLE TESSER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2010
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 MICHAELS CT APT 7
MUKWONAGO WI
53149-1175
US

IV. Provider business mailing address

333 SMITH AVE N
SAINT PAUL MN
55102-2344
US

V. Phone/Fax

Practice location:
  • Phone: 920-410-6719
  • Fax:
Mailing address:
  • Phone: 190-410-6719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number120305
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: