Basic Information
| Provider Information | |||||||||
| NPI: | 1790209161 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MILBOCKER | ||||||||
| FirstName: | TAMMY | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 560 W MITCHELL ST STE 505 | ||||||||
| Address2: | |||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497702277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2314872100 | ||||||||
| FaxNumber: | 2314871909 | ||||||||
| Practice Location | |||||||||
| Address1: | 560 W MITCHELL ST STE 505 | ||||||||
| Address2: | |||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497702277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2314872100 | ||||||||
| FaxNumber: | 2314871909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2017 | ||||||||
| LastUpdateDate: | 07/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704201808 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 4704201808 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.