Provider Demographics
NPI:1255949426
Name:EASTRIDGE, TAMMY LYNN (RN)
Entity type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:LYNN
Last Name:EASTRIDGE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6283 TEASDALE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:MS
Mailing Address - Zip Code:38921-9761
Mailing Address - Country:US
Mailing Address - Phone:662-614-0808
Mailing Address - Fax:
Practice Address - Street 1:516 E NIZHONI BLVD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5748
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS862849163WM0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn