Provider Demographics
NPI:1467643825
Name:ANDERSON, TAMELA RENEE
Entity Type:Individual
Prefix:MRS
First Name:TAMELA
Middle Name:RENEE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:TAMELA
Other - Middle Name:RENEE
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2618-A MAX CLELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-4495
Mailing Address - Country:US
Mailing Address - Phone:678-526-8733
Mailing Address - Fax:678-526-9367
Practice Address - Street 1:2618-A MAX CLELAND BLVD
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-4495
Practice Address - Country:US
Practice Address - Phone:678-526-8733
Practice Address - Fax:678-526-9367
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver