Provider Demographics
NPI:1346649720
Name:BLANK, TAMMY (EXECUTIVE DIRECTOR)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:BLANK
Suffix:
Gender:F
Credentials:EXECUTIVE DIRECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 HARRIS ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75964-5205
Mailing Address - Country:US
Mailing Address - Phone:936-569-6350
Mailing Address - Fax:936-560-1797
Practice Address - Street 1:621 HARRIS ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75964-5205
Practice Address - Country:US
Practice Address - Phone:936-569-6350
Practice Address - Fax:936-560-1797
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX751579473133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist