Healthcare Provider Details

I. General information

NPI: 1114763281
Provider Name (Legal Business Name): TELLY HUNTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 AMERICAN AVE
WAUKESHA WI
53188-5031
US

IV. Provider business mailing address

1786 KELBERG AVE
HOFFMAN ESTATES IL
60192-4808
US

V. Phone/Fax

Practice location:
  • Phone: 262-928-7087
  • Fax:
Mailing address:
  • Phone: 847-660-8754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number15626-33
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number15626
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: