Provider Demographics
NPI:1669017356
Name:VAUTAW, TAMMY LORRAINE
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:LORRAINE
Last Name:VAUTAW
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 1:807 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:ELWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46036-2406
Mailing Address - Country:US
Mailing Address - Phone:765-717-6181
Mailing Address - Fax:765-557-7153
Practice Address - Street 1:807 S 16TH ST
Practice Address - Street 2:
Practice Address - City:ELWOOD
Practice Address - State:IN
Practice Address - Zip Code:46036-2406
Practice Address - Country:US
Practice Address - Phone:765-717-6181
Practice Address - Fax:765-557-7153
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-17
Last Update Date:2019-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN376J00000X, 385H00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No376J00000XNursing Service Related ProvidersHomemaker
No385H00000XRespite Care FacilityRespite Care