Provider Demographics
NPI:1003195553
Name:PHILLIPS, TAMMY DIANE (RN)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:DIANE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:DIANE
Other - Last Name:BURDETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:49 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18407-2113
Mailing Address - Country:US
Mailing Address - Phone:570-558-3232
Mailing Address - Fax:
Practice Address - Street 1:49 GROVE ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:PA
Practice Address - Zip Code:18407-2113
Practice Address - Country:US
Practice Address - Phone:570-558-3232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN541413163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse