Provider Demographics
NPI:1134695190
Name:BLACK, TAMMERA
Entity Type:Individual
Prefix:
First Name:TAMMERA
Middle Name:
Last Name:BLACK
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 1:1969 WESTPOINTE CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-8183
Mailing Address - Country:US
Mailing Address - Phone:407-960-0192
Mailing Address - Fax:
Practice Address - Street 1:1969 WESTPOINTE CIR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835
Practice Address - Country:US
Practice Address - Phone:407-960-0192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL832107134Medicaid