Individual
COURTNEY L TELLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
102 S HENNEPIN AVE, DIXON, IL 61021-3013
(815) 285-8523
(815) 285-8901
Mailing address
102 S HENNEPIN AVE, DIXON, IL 61021-3013
(815) 285-8523
(815) 285-8901
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
085004426
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
329785745001
—
IL
01
—
381220033
MEDICARE
IL
Enumeration date
09/28/2012
Last updated
08/27/2018
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