Provider Demographics
NPI:1598985939
Name:ENTWISTLE, TINA RENEE (DPM)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:RENEE
Last Name:ENTWISTLE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6778 MILL RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6778 MILL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2502
Practice Address - Country:US
Practice Address - Phone:815-227-0041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-005194213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery