Provider Demographics
NPI:1114250966
Name:BLEVINS, TAMMIE L (ANP)
Entity Type:Individual
Prefix:
First Name:TAMMIE
Middle Name:L
Last Name:BLEVINS
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:TAMMIE
Other - Middle Name:L
Other - Last Name:ZIMMERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP-C
Mailing Address - Street 1:390 MAPLE SUMMIT RD
Mailing Address - Street 2:
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-2000
Mailing Address - Country:US
Mailing Address - Phone:618-498-7518
Mailing Address - Fax:618-498-3052
Practice Address - Street 1:270 MAPLE SUMMIT RD
Practice Address - Street 2:
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052-2004
Practice Address - Country:US
Practice Address - Phone:618-498-7108
Practice Address - Fax:618-498-7919
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-11
Last Update Date:2017-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007631363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL376013958OtherTIN
IL376013958OtherTIN