Provider Demographics
NPI:1003447079
Name:SHELBY, TAMMIE LYNETTE
Entity Type:Individual
Prefix:
First Name:TAMMIE
Middle Name:LYNETTE
Last Name:SHELBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2696 WICK ST SE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-5447
Mailing Address - Country:US
Mailing Address - Phone:614-620-0197
Mailing Address - Fax:
Practice Address - Street 1:2686 WICK ST SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-5447
Practice Address - Country:US
Practice Address - Phone:614-620-0197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401558070813376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide