1568222933 NPI number — COLLY TETTELBACH RN, MS, MA, CPE

Table of content: COLLY TETTELBACH RN, MS, MA, CPE (NPI 1568222933)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568222933 NPI number — COLLY TETTELBACH RN, MS, MA, CPE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TETTELBACH
Provider First Name:
COLLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN, MS, MA, CPE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCHENRY
Provider Other First Name:
COLLY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1568222933
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8545 CARMEL VALLEY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARMEL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93923-9556
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-626-4548
Provider Business Mailing Address Fax Number:
831-625-9827

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8545 CARMEL VALLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARMEL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93923-9556
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-626-4548
Provider Business Practice Location Address Fax Number:
831-625-9827
Provider Enumeration Date:
03/21/2024

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP1600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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