Provider Demographics
NPI:1740604594
Name:KING, TAMMIE
Entity Type:Individual
Prefix:
First Name:TAMMIE
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22927 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2716
Mailing Address - Country:US
Mailing Address - Phone:313-613-0485
Mailing Address - Fax:
Practice Address - Street 1:22927 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2716
Practice Address - Country:US
Practice Address - Phone:313-613-0485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-14
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704270233163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse