Provider Demographics
NPI:1144617028
Name:EDMISTON, TAMMIE LYNN
Entity Type:Individual
Prefix:
First Name:TAMMIE
Middle Name:LYNN
Last Name:EDMISTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMMIE
Other - Middle Name:LYNN
Other - Last Name:BOLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:205 SW TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66603-3031
Mailing Address - Country:US
Mailing Address - Phone:785-232-6874
Mailing Address - Fax:
Practice Address - Street 1:205 SW TAYLOR ST
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66603-3031
Practice Address - Country:US
Practice Address - Phone:785-232-6874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-18
Last Update Date:2015-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-89706-122163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse