Provider Demographics
NPI:1295559680
Name:TANTIWONGSE, JAMIE LYNN
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:TANTIWONGSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:LYNN
Other - Last Name:DRYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 84
Mailing Address - Street 2:
Mailing Address - City:HORNER
Mailing Address - State:WV
Mailing Address - Zip Code:26372-0084
Mailing Address - Country:US
Mailing Address - Phone:304-838-0311
Mailing Address - Fax:
Practice Address - Street 1:168 QUARRY GLENN DR APT 705
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WV
Practice Address - Zip Code:26452-9690
Practice Address - Country:US
Practice Address - Phone:304-838-0311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency