Provider Demographics
NPI:1558816561
Name:FRESKE, TANYA (CNP)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:FRESKE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 4TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56334-1820
Mailing Address - Country:US
Mailing Address - Phone:866-667-4747
Mailing Address - Fax:
Practice Address - Street 1:417 FRANKLIN ST S
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:MN
Practice Address - Zip Code:56334-1518
Practice Address - Country:US
Practice Address - Phone:320-634-5157
Practice Address - Fax:320-634-2244
Is Sole Proprietor?:No
Enumeration Date:2016-08-19
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP4748363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner