Provider Demographics
NPI:1013246321
Name:CLARKJORGENSEN, TAMMY LEE (LPN)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:LEE
Last Name:CLARKJORGENSEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:TAMMY
Other - Middle Name:L
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:912 CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-2925
Mailing Address - Country:US
Mailing Address - Phone:920-723-4124
Mailing Address - Fax:
Practice Address - Street 1:912 CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-2925
Practice Address - Country:US
Practice Address - Phone:920-723-4124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-15
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34047-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse