1720689920 NPI number — MS. TAMMY LYNN PROHOFSKY APRN, CNP

Table of content: MS. TAMMY LYNN PROHOFSKY APRN, CNP (NPI 1720689920)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720689920 NPI number — MS. TAMMY LYNN PROHOFSKY APRN, CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PROHOFSKY
Provider First Name:
TAMMY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
APRN, CNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PERTTULA
Provider Other First Name:
TAMMY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN, CNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720689920
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12490 FAIRBANKS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONSDALE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55046-4475
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-257-9280
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11000 OPTUM CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDEN PRAIRIE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55344-2503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-686-2504
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/04/2020

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: 363L00000X , with the licence number:  7897 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X , with the licence number: R147035-4 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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