Provider Demographics
NPI:1265835102
Name:MICCO, TAMMY LYNN (NP)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:LYNN
Last Name:MICCO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4650 HILLS AND DALES RD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708
Mailing Address - Country:US
Mailing Address - Phone:330-649-9400
Mailing Address - Fax:330-649-8059
Practice Address - Street 1:4650 HILLS AND DALES RD NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708
Practice Address - Country:US
Practice Address - Phone:330-649-9400
Practice Address - Fax:330-649-8059
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-07
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH16567363L00000X
OHNP16567363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH16567OtherLICENSE NUMBER