Provider Demographics
NPI:1942713029
Name:PATRICK, TAMARA NICOLE (PT,DPT)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:NICOLE
Last Name:PATRICK
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 W TIETAN ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4363
Mailing Address - Country:US
Mailing Address - Phone:506-522-0114
Mailing Address - Fax:931-455-4450
Practice Address - Street 1:275 W TIETAN ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4363
Practice Address - Country:US
Practice Address - Phone:506-522-0114
Practice Address - Fax:931-455-4450
Is Sole Proprietor?:No
Enumeration Date:2017-11-10
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501018482225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist