Provider Demographics
NPI:1518374529
Name:BRISCOE, TAMMY
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:BRISCOE
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 787
Mailing Address - Street 2:
Mailing Address - City:JOELTON
Mailing Address - State:TN
Mailing Address - Zip Code:37080-0787
Mailing Address - Country:US
Mailing Address - Phone:615-876-7185
Mailing Address - Fax:615-876-4412
Practice Address - Street 1:7089 WHITES CREEK PIKE
Practice Address - Street 2:
Practice Address - City:JOELTON
Practice Address - State:TN
Practice Address - Zip Code:37080-8665
Practice Address - Country:US
Practice Address - Phone:615-876-7185
Practice Address - Fax:615-876-4412
Is Sole Proprietor?:No
Enumeration Date:2014-07-22
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN51565171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH445130Medicaid