Provider Demographics
NPI:1093958860
Name:PANGBURN, TAMMY L
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:L
Last Name:PANGBURN
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 1:1830 NE 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909-4750
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8359 BEACON BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3048
Practice Address - Country:US
Practice Address - Phone:239-514-4351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist