Provider Demographics
NPI:1619489473
Name:GRISHAM, TAMMY (NP-C)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:GRISHAM
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 NW LEONARDO CIR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-4354
Mailing Address - Country:US
Mailing Address - Phone:954-448-3913
Mailing Address - Fax:
Practice Address - Street 1:714 NW LEONARDO CIR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-4354
Practice Address - Country:US
Practice Address - Phone:954-448-3913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9203521363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty