Provider Demographics
NPI:1558610303
Name:VINES, TAMMY
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:
Last Name:VINES
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 1:4271 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:AYDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28513-7107
Mailing Address - Country:US
Mailing Address - Phone:252-746-6388
Mailing Address - Fax:252-746-6388
Practice Address - Street 1:4271 HIGH ST
Practice Address - Street 2:
Practice Address - City:AYDEN
Practice Address - State:NC
Practice Address - Zip Code:28513-7107
Practice Address - Country:US
Practice Address - Phone:252-746-6388
Practice Address - Fax:252-746-6388
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-074-039310400000X
FCL-074-039343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)