Provider Demographics
NPI:1952844540
Name:DESHAZOR, TAMMY RENEE
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:RENEE
Last Name:DESHAZOR
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 1:661 ARNETT BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-2506
Mailing Address - Country:US
Mailing Address - Phone:434-857-2632
Mailing Address - Fax:
Practice Address - Street 1:661 ARNETT BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-2506
Practice Address - Country:US
Practice Address - Phone:434-857-2632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-30
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver