Provider Demographics
NPI:1336202498
Name:EVANS, TAMMY L
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:L
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:L
Other - Last Name:PRIGANC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5150 FOUNTAINS DR S
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-5715
Mailing Address - Country:US
Mailing Address - Phone:843-455-2415
Mailing Address - Fax:
Practice Address - Street 1:5150 FOUNTAINS DR S
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-5715
Practice Address - Country:US
Practice Address - Phone:843-455-2415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC38412251P0200X
FL379082251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112495700Medicaid
SCTH1333Medicaid