Provider Demographics
NPI:1669850467
Name:AHMOUDA, TAMMY SUE (PN102856-MEDS)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:SUE
Last Name:AHMOUDA
Suffix:
Gender:F
Credentials:PN102856-MEDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1366 VIMLA WAY
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-5731
Mailing Address - Country:US
Mailing Address - Phone:937-559-2483
Mailing Address - Fax:
Practice Address - Street 1:1366 VIMLA WAY
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-5731
Practice Address - Country:US
Practice Address - Phone:937-559-2483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.102856164W00000X, 174H00000X
MS2013045400164W00000X
OHRR470365172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No172A00000XOther Service ProvidersDriver
No174H00000XOther Service ProvidersHealth Educator