Provider Demographics
NPI:1376944371
Name:WECKERLY, TAMMY LYNN (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:LYNN
Last Name:WECKERLY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:LYNN
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:811 FOURNIE ST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-5307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:811 FOURNIE ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-5307
Practice Address - Country:US
Practice Address - Phone:989-964-1078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-09
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI104788367500000X
MI4704234470163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse