Provider Demographics
NPI:1639172182
Name:WINGO, TAMMY JIBBEN (FNP)
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:JIBBEN
Last Name:WINGO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 585
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-0585
Mailing Address - Country:US
Mailing Address - Phone:434-394-2422
Mailing Address - Fax:434-394-2435
Practice Address - Street 1:1100 W 3RD ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-2628
Practice Address - Country:US
Practice Address - Phone:434-394-2422
Practice Address - Fax:434-394-2435
Is Sole Proprietor?:No
Enumeration Date:2005-05-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024129303363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024129303OtherLICENSE
VA010262020Medicaid
VAC09816OtherMEDICARE GROUP NO
VAMW0718900OtherDEA NUMBER
VA010262020Medicaid
VAC09816OtherMEDICARE GROUP NO