Provider Demographics
NPI:1013664911
Name:KIENZLE, TAMMIE
Entity Type:Individual
Prefix:MRS
First Name:TAMMIE
Middle Name:
Last Name:KIENZLE
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:TAMMIE
Other - Middle Name:
Other - Last Name:PUTNEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:26 WESTMOYLAN LN
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-1121
Mailing Address - Country:US
Mailing Address - Phone:516-972-4881
Mailing Address - Fax:
Practice Address - Street 1:14 RESEARCH WAY
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3453
Practice Address - Country:US
Practice Address - Phone:631-331-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist