Provider Demographics
NPI:1164277844
Name:VILLAVICENCIO, TAMARA ANNE (RN)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:ANNE
Last Name:VILLAVICENCIO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:ANNE
Other - Last Name:SHANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3605 E ARBUTUS DR
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-4042
Mailing Address - Country:US
Mailing Address - Phone:517-348-3283
Mailing Address - Fax:
Practice Address - Street 1:3605 E ARBUTUS DR
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-4042
Practice Address - Country:US
Practice Address - Phone:517-348-3283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704388836163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse