Provider Demographics
NPI:1760572630
Name:HANSULD (WELCH), TIA JEAN (FNP)
Entity Type:Individual
Prefix:MS
First Name:TIA
Middle Name:JEAN
Last Name:HANSULD (WELCH)
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:TIA
Other - Middle Name:JEAN
Other - Last Name:WELCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANA CERTIFICATION
Mailing Address - Street 1:680 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-1759
Mailing Address - Country:US
Mailing Address - Phone:307-237-7569
Mailing Address - Fax:307-237-2036
Practice Address - Street 1:680 E 18TH ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-4703
Practice Address - Country:US
Practice Address - Phone:307-259-6870
Practice Address - Fax:307-237-2036
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY9090.162363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily