Provider Demographics
NPI:1295405249
Name:GAETH, TAMIE LYNN
Entity Type:Individual
Prefix:
First Name:TAMIE
Middle Name:LYNN
Last Name:GAETH
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 1:2762 PIGEON RD
Mailing Address - Street 2:
Mailing Address - City:BAD AXE
Mailing Address - State:MI
Mailing Address - Zip Code:48413-9738
Mailing Address - Country:US
Mailing Address - Phone:989-551-5204
Mailing Address - Fax:
Practice Address - Street 1:2762 PIGEON RD
Practice Address - Street 2:
Practice Address - City:BAD AXE
Practice Address - State:MI
Practice Address - Zip Code:48413-9738
Practice Address - Country:US
Practice Address - Phone:989-551-5204
Practice Address - Fax:989-269-0224
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2883533374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI86-1482247Medicaid