Provider Demographics
NPI:1609235068
Name:PATTERSON, TONYA L
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:L
Last Name:PATTERSON
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 1:7041 34TH AVE E
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:FL
Mailing Address - Zip Code:34221-7391
Mailing Address - Country:US
Mailing Address - Phone:941-417-9848
Mailing Address - Fax:
Practice Address - Street 1:7041 34TH AVE E
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:FL
Practice Address - Zip Code:34221-7391
Practice Address - Country:US
Practice Address - Phone:941-417-9848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-14
Last Update Date:2016-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014369000Medicaid