Provider Demographics
NPI:1104903061
Name:BOXLEITNER, TAMMY JO (APN)
Entity type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:JO
Last Name:BOXLEITNER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:MS
Other - First Name:TAMMY
Other - Middle Name:JO
Other - Last Name:HENNING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP, APN
Mailing Address - Street 1:1905 E. HUEBBE PARKWAY
Mailing Address - Street 2:BELOIT HEALTH SYSTEM, INC
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1842
Mailing Address - Country:US
Mailing Address - Phone:608-364-2200
Mailing Address - Fax:608-363-7395
Practice Address - Street 1:1969 WEST HART ROAD
Practice Address - Street 2:BELOIT MEMORIAL HOSPITAL, INC.
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-2298
Practice Address - Country:US
Practice Address - Phone:608-364-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-003115363L00000X
WI4577-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQ73364Medicare UPIN