Provider Demographics
NPI:1679521611
Name:TOMMERUP, TIMOTHY ALLEN (MS, ATC)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:ALLEN
Last Name:TOMMERUP
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 STRATFORD DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1814
Mailing Address - Country:US
Mailing Address - Phone:859-373-0489
Mailing Address - Fax:
Practice Address - Street 1:300 N BROADWAY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508-1797
Practice Address - Country:US
Practice Address - Phone:859-233-8850
Practice Address - Fax:859-233-8638
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT6242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer