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General NPI Number Information
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NPI Number | 1518787696
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Entity Type | Individual
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Provider Name | MITCHELL GLENN EUSTAQUIO TAN DNP, APRN,PMHNP-BC
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Gender | Male
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Dates
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Enumeration Date | 10/14/2024
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Last Update Date | 03/25/2025
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Provider Practice Location Address
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Address Line | 1639 N ALPINE RD STE 260
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City | ROCKFORD
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State | IL
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Zip | 61107-1481
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Country | US
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Telephone | 815-670-1715
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Fax |
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Provider Business Mailing Address
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Address Line | 5126 SILVER FOX TRL
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City | ROCKFORD
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State | IL
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Zip | 61114-7010
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Country | US
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Telephone | 815-670-1715
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 4704421713
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 041502075
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 1632233
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License Number State | WI
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Taxonomy #4
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 209031254
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License Number State | IL
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