Provider Demographics
NPI:1063843555
Name:KOONCE, TAMMY (RN)
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:
Last Name:KOONCE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 E WENDOVER AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-6713
Mailing Address - Country:US
Mailing Address - Phone:336-641-5598
Mailing Address - Fax:
Practice Address - Street 1:1100 E WENDOVER AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6713
Practice Address - Country:US
Practice Address - Phone:336-641-5598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC140708163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse