Provider Demographics
NPI:1417462961
Name:MIX, TAMMY L (LPN)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:L
Last Name:MIX
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 1:221 FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-4116
Mailing Address - Country:US
Mailing Address - Phone:740-408-1279
Mailing Address - Fax:
Practice Address - Street 1:765 PIERCE DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43223-2425
Practice Address - Country:US
Practice Address - Phone:614-223-1650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH104379164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse