Provider Demographics
NPI:1376704940
Name:TANCABEL, KATIE NICOLE (OD)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:NICOLE
Last Name:TANCABEL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 ELM ST E
Mailing Address - Street 2:PO BOX 128
Mailing Address - City:ANNANDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55302-1149
Mailing Address - Country:US
Mailing Address - Phone:320-274-3701
Mailing Address - Fax:320-274-3784
Practice Address - Street 1:500 ELM ST E
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:MN
Practice Address - Zip Code:55302-1149
Practice Address - Country:US
Practice Address - Phone:320-274-3701
Practice Address - Fax:320-274-3784
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3139152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist