Provider Demographics
NPI:1689127615
Name:JUSTICE, TAMMY (OFFICE MANAGER)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:OFFICE MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 BRYAN ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:HUNTINGDON
Mailing Address - State:PA
Mailing Address - Zip Code:16652-2413
Mailing Address - Country:US
Mailing Address - Phone:814-643-6300
Mailing Address - Fax:
Practice Address - Street 1:900 BRYAN ST
Practice Address - Street 2:SUITE 5
Practice Address - City:HUNTINGDON
Practice Address - State:PA
Practice Address - Zip Code:16652-2413
Practice Address - Country:US
Practice Address - Phone:814-643-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2022-04-26
Deactivation Date:2019-05-29
Deactivation Code:
Reactivation Date:2022-04-26
Provider Licenses
StateLicense IDTaxonomies
PAPN097247L164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1740463470Medicaid
PA1740463470Medicare NSC