Provider Demographics
NPI:1225274814
Name:BEAULIEU, TAMMY
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:BEAULIEU
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 1:17 SOUTH STREET
Mailing Address - Street 2:
Mailing Address - City:SELKIRK
Mailing Address - State:NY
Mailing Address - Zip Code:12158
Mailing Address - Country:US
Mailing Address - Phone:518-767-2119
Mailing Address - Fax:
Practice Address - Street 1:17 SOUTH STREET
Practice Address - Street 2:
Practice Address - City:SELKIRK
Practice Address - State:NY
Practice Address - Zip Code:12158
Practice Address - Country:US
Practice Address - Phone:518-767-2119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-02
Last Update Date:2009-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker