Provider Demographics
NPI:1134725740
Name:LY, TOUCHELLA (FNP-BC)
Entity type:Individual
Prefix:MR
First Name:TOUCHELLA
Middle Name:
Last Name:LY
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 PARK RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-1592
Mailing Address - Country:US
Mailing Address - Phone:920-264-7033
Mailing Address - Fax:
Practice Address - Street 1:1050 PARK RIDGE AVE
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-1592
Practice Address - Country:US
Practice Address - Phone:920-264-7033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10496-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily