Provider Demographics
NPI:1013112077
Name:JAVELLANA, TAMMY (FNP)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:JAVELLANA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 WOODLAWN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-3134
Mailing Address - Country:US
Mailing Address - Phone:731-478-6064
Mailing Address - Fax:731-285-6964
Practice Address - Street 1:1505 WOODLAWN AVE STE A
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-3134
Practice Address - Country:US
Practice Address - Phone:731-478-6064
Practice Address - Fax:731-478-6067
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN10445363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1515958Medicaid
TN1013112077OtherNPI
TNQ24095Medicare UPIN