Basic Information
| Provider Information | |||||||||
| NPI: | 1497411797 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TEBO | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | FRANCES | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 781076 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 118 W DREXEL PKWY | ||||||||
| Address2: | |||||||||
| City: | RENSSELAER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479787344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198664300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2021 | ||||||||
| LastUpdateDate: | 02/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71011915A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | 28190154A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.