Provider Demographics
NPI:1417404021
Name:JEAN PIERRE, TAMARA III
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:JEAN PIERRE
Suffix:III
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 1:742 S FAIRVIEW TER FL 33825
Mailing Address - Street 2:
Mailing Address - City:AVON PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33825-4451
Mailing Address - Country:US
Mailing Address - Phone:863-212-4777
Mailing Address - Fax:863-453-3201
Practice Address - Street 1:742 S FAIR VIEW TERR
Practice Address - Street 2:
Practice Address - City:AVON PARK
Practice Address - State:FL
Practice Address - Zip Code:33825
Practice Address - Country:US
Practice Address - Phone:863-212-4777
Practice Address - Fax:863-453-3201
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL234186251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL463965717Medicaid
FL463965717Medicaid