Provider Demographics
NPI:1578691994
Name:CLARK, TAMMI LYNN (LPT)
Entity Type:Individual
Prefix:MS
First Name:TAMMI
Middle Name:LYNN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:162 E CARSON ST
Mailing Address - Street 2:
Mailing Address - City:COLUSA
Mailing Address - State:CA
Mailing Address - Zip Code:95932-2880
Mailing Address - Country:US
Mailing Address - Phone:530-458-0527
Mailing Address - Fax:530-458-8088
Practice Address - Street 1:162 E CARSON ST
Practice Address - Street 2:
Practice Address - City:COLUSA
Practice Address - State:CA
Practice Address - Zip Code:95932-2880
Practice Address - Country:US
Practice Address - Phone:530-458-0520
Practice Address - Fax:530-458-8088
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25521167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician