Provider Demographics
NPI:1518787696
Name:TAN, MITCHELL GLENN EUSTAQUIO (DNP, APRN,PMHNP-BC)
Entity type:Individual
Prefix:DR
First Name:MITCHELL GLENN
Middle Name:EUSTAQUIO
Last Name:TAN
Suffix:
Gender:M
Credentials:DNP, APRN,PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5126 SILVER FOX TRL
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-7010
Mailing Address - Country:US
Mailing Address - Phone:815-670-1715
Mailing Address - Fax:
Practice Address - Street 1:1639 N ALPINE RD STE 260
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-1481
Practice Address - Country:US
Practice Address - Phone:815-670-1715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-14
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704421713363LP0808X
IL041502075163W00000X
WI1632233363LP0808X
IL209031254363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse