Provider Demographics
NPI:1760403141
Name:RICKEY, TAMI LYNN (NP)
Entity Type:Individual
Prefix:MRS
First Name:TAMI
Middle Name:LYNN
Last Name:RICKEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TAMI
Other - Middle Name:
Other - Last Name:BROADWATER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:4700 PUDDLEDOCK ROAD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PRINCE GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23875-1268
Mailing Address - Country:US
Mailing Address - Phone:804-526-1111
Mailing Address - Fax:804-526-8363
Practice Address - Street 1:4700 PUDDLEDOCK ROAD
Practice Address - Street 2:SUITE 300
Practice Address - City:PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23875-1268
Practice Address - Country:US
Practice Address - Phone:804-526-1111
Practice Address - Fax:804-526-8363
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024165943363LW0102X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005641276Medicaid
P15699Medicare UPIN