Provider Demographics
NPI:1679639355
Name:BRANNON, TAMMY C (MS,PT)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:C
Last Name:BRANNON
Suffix:
Gender:F
Credentials:MS,PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:634 TOMMY AARON DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-1504
Mailing Address - Country:US
Mailing Address - Phone:770-503-7337
Mailing Address - Fax:770-503-7337
Practice Address - Street 1:634 TOMMY AARON DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30506-1504
Practice Address - Country:US
Practice Address - Phone:770-503-7337
Practice Address - Fax:770-503-7337
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0047912251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00776916AMedicaid