Provider Demographics
NPI:1831283894
Name:PREWITT, TAMMY L (FNP)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:L
Last Name:PREWITT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:
Other - Last Name:SIMERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:20 THE LEGENDS PKWY
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-3801
Mailing Address - Country:US
Mailing Address - Phone:636-938-3399
Mailing Address - Fax:636-938-9609
Practice Address - Street 1:20 THE LEGENDS PKWY
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:MO
Practice Address - Zip Code:63025-3801
Practice Address - Country:US
Practice Address - Phone:636-938-3399
Practice Address - Fax:636-938-9609
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO131584363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1831283894Medicaid
MO1831283894Medicaid
MO152810013Medicare PIN
MOP50939Medicare UPIN
MO500360066Medicare PIN