Provider Demographics
NPI:1073893624
Name:PELEGRIN, TAMMY L (NP)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:L
Last Name:PELEGRIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:L
Other - Last Name:BURKHALTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:901-227-3255
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:504 AZALEA DR
Practice Address - Street 2:STE A
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5397
Practice Address - Country:US
Practice Address - Phone:662-236-7738
Practice Address - Fax:662-236-9642
Is Sole Proprietor?:No
Enumeration Date:2011-08-26
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR871187363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily