Provider Demographics
NPI:1871060731
Name:RETTIG, TANYA (NP)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:RETTIG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1803 OKLAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:GREAT LAKES
Mailing Address - State:IL
Mailing Address - Zip Code:60088-4214
Mailing Address - Country:US
Mailing Address - Phone:815-388-2424
Mailing Address - Fax:
Practice Address - Street 1:7804 WOODED SHORE DR
Practice Address - Street 2:
Practice Address - City:WONDER LAKE
Practice Address - State:IL
Practice Address - Zip Code:60097-9312
Practice Address - Country:US
Practice Address - Phone:815-388-2424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017713363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner