Provider Demographics
NPI:1154576221
Name:MUNGER, TANYA J (NP)
Entity type:Individual
Prefix:MS
First Name:TANYA
Middle Name:J
Last Name:MUNGER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:J
Other - Last Name:MONTAVON/WHITMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:1235 MORTH ROAD
Mailing Address - Street 2:SUITE 222
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3879
Mailing Address - Country:US
Mailing Address - Phone:815-397-8400
Mailing Address - Fax:815-229-0050
Practice Address - Street 1:1235 N MULFORD RD
Practice Address - Street 2:SUITE 222
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3879
Practice Address - Country:US
Practice Address - Phone:815-397-8400
Practice Address - Fax:815-229-0050
Is Sole Proprietor?:No
Enumeration Date:2008-11-17
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041322477163W00000X
IL309003966363LF0000X
IL209007248363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily