Provider Demographics
NPI:1801210786
Name:BOSTELMAN, TAMMY
Entity Type:Individual
Prefix:MS
First Name:TAMMY
Middle Name:
Last Name:BOSTELMAN
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 1:802 W INDIANA ST
Mailing Address - Street 2:
Mailing Address - City:EDON
Mailing Address - State:OH
Mailing Address - Zip Code:43518-9627
Mailing Address - Country:US
Mailing Address - Phone:419-272-3213
Mailing Address - Fax:
Practice Address - Street 1:802 W INDIANA ST
Practice Address - Street 2:
Practice Address - City:EDON
Practice Address - State:OH
Practice Address - Zip Code:43518-9627
Practice Address - Country:US
Practice Address - Phone:419-272-3213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHDF1002221174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist