MEDICARE: JULIE GUENTHER TEBBEN CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LW0102X	Women's Health Nurse Practitioner	R119158-1	MN

General Provider Information

NPI Number	:	1336405166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIE GUENTHER TEBBEN CNP

Provider Business Mailing Address
First Line	:	3485 WILLOW LAKE BLVD
Second Line	:	SUITE 100
City	:	VADNAIS HEIGHTS
State	:	MN
Zip	:	55110-5152
Country	:	US
Telephone Number	:	651-484-5567
Fax Number	:	165-134-4440

Provider Business Practice Location Address
First Line	:	3485 WILLOW LAKE BLVD
Second Line	:	SUITE 100
City	:	VADNAIS HEIGHTS
State	:	MN
Zip	:	55110-5152
Country	:	US
Telephone Number	:	651-484-5567
Fax Number	:	165-134-4440

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2012
Last Update Date	:	04/05/2012

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