Provider Demographics
NPI:1164153219
Name:CLAY, TAMMY DENISE
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:DENISE
Last Name:CLAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:DENISE
Other - Last Name:WARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:133 E SYKES RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39212-4988
Mailing Address - Country:US
Mailing Address - Phone:601-937-2999
Mailing Address - Fax:
Practice Address - Street 1:133 E SYKES RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39212-4988
Practice Address - Country:US
Practice Address - Phone:601-937-2999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS882883566Medicaid