Provider Demographics
NPI:1902178999
Name:DAVIS, TAMMARA IVY (PTA)
Entity Type:Individual
Prefix:
First Name:TAMMARA
Middle Name:IVY
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 PRIM RD
Mailing Address - Street 2:
Mailing Address - City:PRIM
Mailing Address - State:AR
Mailing Address - Zip Code:72130-9526
Mailing Address - Country:US
Mailing Address - Phone:870-615-1555
Mailing Address - Fax:
Practice Address - Street 1:706 OAK GROVE ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:AR
Practice Address - Zip Code:72560-8601
Practice Address - Country:US
Practice Address - Phone:870-269-7059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1920225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant