Provider Demographics
NPI:1689789299
Name:EIKSTADT, TANYA NADINE (MS ED, ATC)
Entity Type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:NADINE
Last Name:EIKSTADT
Suffix:
Gender:F
Credentials:MS ED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1827 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-4620
Mailing Address - Country:US
Mailing Address - Phone:815-871-4859
Mailing Address - Fax:
Practice Address - Street 1:5510 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2381
Practice Address - Country:US
Practice Address - Phone:815-395-4505
Practice Address - Fax:815-395-4507
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer