Provider Demographics
NPI:1205132172
Name:KNOUP, TANYA MARIE (DT)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:MARIE
Last Name:KNOUP
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8475 W MOUND RD
Mailing Address - Street 2:
Mailing Address - City:LENA
Mailing Address - State:IL
Mailing Address - Zip Code:61048-9016
Mailing Address - Country:US
Mailing Address - Phone:815-238-8908
Mailing Address - Fax:
Practice Address - Street 1:8475 W MOUND RD
Practice Address - Street 2:
Practice Address - City:LENA
Practice Address - State:IL
Practice Address - Zip Code:61048-9016
Practice Address - Country:US
Practice Address - Phone:815-238-8908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker