Provider Demographics
NPI:1578776449
Name:HEBERT, TAMMY L (OTR)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:L
Last Name:HEBERT
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2538 S. 65TH ST.
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66106-5415
Mailing Address - Country:US
Mailing Address - Phone:913-375-1431
Mailing Address - Fax:
Practice Address - Street 1:2538 S. 65TH ST.
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66106-5415
Practice Address - Country:US
Practice Address - Phone:913-375-1431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17-01439171W00000X
MO2001026998171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
J82C567AMedicare PIN