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General NPI Number Information
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NPI Number | 1598985939
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Entity Type | Individual
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Provider Name | TINA RENEE ENTWISTLE D.P.M.
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Gender | Female
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Dates
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Enumeration Date | 04/26/2007
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Last Update Date | 01/11/2011
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Provider Practice Location Address
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Address Line | 6778 MILL RD SUITE 100
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City | ROCKFORD
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State | IL
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Zip | 61108-2502
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Country | US
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Telephone | 815-227-0041
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Fax |
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Provider Business Mailing Address
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Address Line | 6778 MILL RD SUITE 100
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City | ROCKFORD
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State | IL
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Zip | 61108-2502
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Country | US
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Telephone |
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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 | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 016-005194
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License Number State | IL
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