Provider Demographics
NPI:1336289271
Name:GEBO, TAMMY LYNN (LPN)
Entity Type:Individual
Prefix:MISS
First Name:TAMMY
Middle Name:LYNN
Last Name:GEBO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 COFFEEN ST
Mailing Address - Street 2:APT 202
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-2461
Mailing Address - Country:US
Mailing Address - Phone:315-788-3465
Mailing Address - Fax:
Practice Address - Street 1:258 CHAMPION ST
Practice Address - Street 2:APT 503
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619-3361
Practice Address - Country:US
Practice Address - Phone:315-493-4937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5893028164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAM22271RMedicaid