Provider Demographics
NPI:1013377787
Name:ANDERSON, TAMICHA LOUETTE (LPN)
Entity Type:Individual
Prefix:
First Name:TAMICHA
Middle Name:LOUETTE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 DINGLEDINE AVE
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-1712
Mailing Address - Country:US
Mailing Address - Phone:419-371-4895
Mailing Address - Fax:
Practice Address - Street 1:904 DINGLEDINE AVE
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-1712
Practice Address - Country:US
Practice Address - Phone:419-371-4895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-24
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH121146164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse