Provider Demographics
NPI:1467095927
Name:OWEN, TAMATHA NICOLE
Entity Type:Individual
Prefix:
First Name:TAMATHA
Middle Name:NICOLE
Last Name:OWEN
Suffix:
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:PO BOX 1258
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:38485-1258
Mailing Address - Country:US
Mailing Address - Phone:931-253-1110
Mailing Address - Fax:256-664-4280
Practice Address - Street 1:1061 HIGHWAY 35 S
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:MS
Practice Address - Zip Code:39074
Practice Address - Country:US
Practice Address - Phone:931-253-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903572363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner