Provider Demographics
NPI:1235602483
Name:MUSGROVE, TAMMY ELAINE
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:ELAINE
Last Name:MUSGROVE
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:TAMMY
Other - Middle Name:JENKINS
Other - Last Name:NEWMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16150 40TH ST
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32060-8015
Mailing Address - Country:US
Mailing Address - Phone:386-590-6961
Mailing Address - Fax:
Practice Address - Street 1:16150 40TH ST
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32060-8015
Practice Address - Country:US
Practice Address - Phone:386-590-6961
Practice Address - Fax:386-362-5005
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant