Provider Demographics
NPI:1902400484
Name:SIDERS, TAMMY MARIE
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:MARIE
Last Name:SIDERS
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 1:783 BRANDY RUN RD
Mailing Address - Street 2:
Mailing Address - City:ELKVIEW
Mailing Address - State:WV
Mailing Address - Zip Code:25071-6918
Mailing Address - Country:US
Mailing Address - Phone:304-444-8719
Mailing Address - Fax:304-471-2488
Practice Address - Street 1:4510 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-4835
Practice Address - Country:US
Practice Address - Phone:304-965-9081
Practice Address - Fax:304-346-1860
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker