Provider Demographics
NPI:1285832873
Name:PARKS, TAMMY JO (LPN)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:JO
Last Name:PARKS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:J
Other - Last Name:VANCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:924 RIGGS AVE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3842
Mailing Address - Country:US
Mailing Address - Phone:315-955-5235
Mailing Address - Fax:
Practice Address - Street 1:924 RIGGS AVE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3842
Practice Address - Country:US
Practice Address - Phone:315-955-5235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261262--1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02528009Medicaid