Provider Demographics
NPI:1497985717
Name:WIDRICK, TAMMY Z
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:Z
Last Name:WIDRICK
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 1:15350 COUNTY ROUTE 76
Mailing Address - Street 2:
Mailing Address - City:ADAMS CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:13606-2146
Mailing Address - Country:US
Mailing Address - Phone:315-284-4002
Mailing Address - Fax:
Practice Address - Street 1:15350 COUNTY ROUTE 76
Practice Address - Street 2:
Practice Address - City:ADAMS CENTER
Practice Address - State:NY
Practice Address - Zip Code:13606-2146
Practice Address - Country:US
Practice Address - Phone:315-284-4002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-21
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203474164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse