Provider Demographics
NPI:1083903819
Name:SURPRIN, TAMMY (MAC, LAC)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:SURPRIN
Suffix:
Gender:F
Credentials:MAC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16322 ELKHORN LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-3267
Mailing Address - Country:US
Mailing Address - Phone:240-687-7833
Mailing Address - Fax:
Practice Address - Street 1:2110 PRIEST BRIDGE DR STE 3
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-2472
Practice Address - Country:US
Practice Address - Phone:240-687-7833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-01
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01883171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist