Tiffany Marie Boelk, APNP
Individual provider Active NPI Nurse Practitioner · Fond Du Lac, WI
NPI 1700459690 · NPPES record last updated Oct 12, 2021
Key facts
- NPI
- 1700459690
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Nurse Practitioner 363L00000X
- License
- 10905-33 (WI)
- Practice address
- 420 E Division St
Fond Du Lac, WI 54935-4560 - Phone
- (920) 923-7400
- NPI assigned
- Jul 20, 2021
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 18
Hospital & facility affiliations 1
Medicare Care Compare profile
- Specialty
- Nurse Practitioner
- Education
- Other, 2020
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- Agnesian Healthcare Inc
Practice addresses (Care Compare)
145 N Main St
Fond Du Lac, WI 54935-3423
Phone (920) 926-8722
Hospital & facility affiliations
- SSM Health St Agnes Hospital-Fond Du Lac
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in WI
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20210903000903 | WI | Practitioner - Nurse Practitioner | 2668878349 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 10905-33 | WI | MD | Family Nurse Practitioner |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Agnesian Healthcare Inc | Current |
Accepting new patients | |
| Agnesian Healthcare, Inc | Current | Accepting new patients | |
| Agnesian Healthcare Inc | Current |
Accepting new patients |
Locations
421 Camelot Dr
Fond du Lac, WI 54935
Phone (920) 923-7940
145 N Main St
Fond du Lac, WI 54935
Phone (920) 926-4660
420 E Division St
Fond du Lac, WI 54935
Phone (920) 923-7400
1808 W Beltline Hwy
Madison, WI 53713
Phone (608) 250-1497
360 S Mountin Dr
Mayville, WI 53050
Phone (920) 387-2111
835 Parkside St
Ripon, WI 54971
Phone (920) 745-3520
608 W Brown St
Waupun, WI 53963
Phone (920) 324-6800
Interoperability endpoints
- tboelk332427@direct-ehr-ssmhc.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Nurse Practitioner | 363LF0000X | 10905-33 | WI | |
| Nurse Practitioner | 363L00000X | 10905-33 | WI | Yes |
Addresses
Primary practice location
420 E Division St
Fond Du Lac, WI 54935-4560
Mailing address
N3087 Hickory Rd
Byron, WI 53006-1126
Phone (920) 517-2207
Other practice location 1
145 N Main St
Fond Du Lac, WI 54935-3423
Phone (920) 926-8492
Other practice location 2
835 Parkside St
Ripon, WI 54971-8505
Phone (920) 745-3520
Other names
- Tiffany Marie Picchiottino
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| Direct Messaging Address | tboelk332427@direct-ehr-ssmhc.com | Direct | |
| FHIR URL | https://fhir.ssmhc.com/fhir/api/FHIR/DSTU2/ | Other |
Other providers in Fond Du Lac, WI
- Blue Lake Smiles
- Sean Blum
- Thomas Blum
- Renee L Bodary
- Samantha Boehnlein
- Jacqueline Lee Bogan
- Sampson Kwabina Boham
- Holly Anne Bohn
- Ruth Marie Bohn
- Shirley Bokelman
All providers in Fond Du Lac, WI · Nurse Practitioner in Wisconsin
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 12, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.