Provider Demographics
NPI:1629353388
Name:ERDLY-TAMBELLINI, JENNIE CATHERINE
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:CATHERINE
Last Name:ERDLY-TAMBELLINI
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 1:4769 BRECH ST SE
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501-4612
Mailing Address - Country:US
Mailing Address - Phone:360-491-0613
Mailing Address - Fax:
Practice Address - Street 1:4769 BRECH ST SE
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-4612
Practice Address - Country:US
Practice Address - Phone:360-491-0613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00004654172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist