Provider Demographics
NPI:1588006449
Name:STATEN, TAMMY REBECCA (LPTA)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:REBECCA
Last Name:STATEN
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5006 MAGNOLIA ESTATES BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-8248
Mailing Address - Country:US
Mailing Address - Phone:615-939-1860
Mailing Address - Fax:615-773-4580
Practice Address - Street 1:5006 MAGNOLIA ESTATES BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-8248
Practice Address - Country:US
Practice Address - Phone:615-568-3832
Practice Address - Fax:615-773-4580
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-20
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPTA0000001875225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPTA0000001875OtherTN LIC. FOR PHYSICAL THERAPY