Provider Demographics
NPI:1902861933
Name:WAGNER, TAMMY N (OTR/L)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:N
Last Name:WAGNER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 LAZY LN
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-4272
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PMRS 117
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:TN
Practice Address - Zip Code:37684
Practice Address - Country:US
Practice Address - Phone:423-926-1171
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2768225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist