Provider Demographics
NPI:1710354303
Name:PEARSON, TAMMIE (RN)
Entity Type:Individual
Prefix:
First Name:TAMMIE
Middle Name:
Last Name:PEARSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 CLOVER CT
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-6722
Mailing Address - Country:US
Mailing Address - Phone:845-634-7413
Mailing Address - Fax:
Practice Address - Street 1:105 S MADISON AVE
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10977-5474
Practice Address - Country:US
Practice Address - Phone:845-577-6049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY653733163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY13-6006910Medicaid