Provider Demographics
NPI:1760732465
Name:HARTENBERGER, TAMARA NICOLE (PT)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:NICOLE
Last Name:HARTENBERGER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 HIGHWAY 314 SW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-9600
Mailing Address - Country:US
Mailing Address - Phone:505-866-0055
Mailing Address - Fax:505-866-0057
Practice Address - Street 1:4516 ARROWHEAD RIDGE DR SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-5932
Practice Address - Country:US
Practice Address - Phone:505-896-4978
Practice Address - Fax:505-994-2842
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-11
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4208225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNMA1030006Medicare PIN