Provider Demographics
NPI:1497061071
Name:LY, TAM
Entity Type:Individual
Prefix:
First Name:TAM
Middle Name:
Last Name:LY
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 1:15317 SANTA GERTRUDES AVE UNIT JJ103
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-5088
Mailing Address - Country:US
Mailing Address - Phone:714-204-2961
Mailing Address - Fax:
Practice Address - Street 1:14112 S KINGSLEY DR
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-3018
Practice Address - Country:US
Practice Address - Phone:310-217-7312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-20
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD8892587390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program