MEDICARE: ELIZABETH TULLY-NUNN

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	2255A2300X	Athletic Trainer	1173	MN

General Provider Information

NPI Number	:	1912306051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH TULLY-NUNN

Provider Business Mailing Address
First Line	:	2000 PLYMOUTH RD
Second Line	:	SUITE 200
City	:	HOPKINS
State	:	MN
Zip	:	55305-2366
Country	:	US
Telephone Number	:	952-545-0663
Fax Number	:

Provider Business Practice Location Address
First Line	:	2000 PLYMOUTH RD
Second Line	:	SUITE 200
City	:	HOPKINS
State	:	MN
Zip	:	55305-2366
Country	:	US
Telephone Number	:	952-545-0663
Fax Number	:

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

Provider Enumeration Date	:	08/14/2014
Last Update Date	:	08/14/2014

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