Provider Demographics
NPI:1639509508
Name:MCCLENDON, TAMMIE D (CNP)
Entity type:Individual
Prefix:
First Name:TAMMIE
Middle Name:D
Last Name:MCCLENDON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26650 EUREKA RD
Mailing Address - Street 2:SUITE C-1
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-4835
Mailing Address - Country:US
Mailing Address - Phone:734-941-4991
Mailing Address - Fax:734-941-4919
Practice Address - Street 1:2500 HAMLIN DR
Practice Address - Street 2:
Practice Address - City:INKSTER
Practice Address - State:MI
Practice Address - Zip Code:48141-2348
Practice Address - Country:US
Practice Address - Phone:313-561-5100
Practice Address - Fax:313-565-0309
Is Sole Proprietor?:No
Enumeration Date:2013-11-13
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704202622363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1639509508Medicaid
MI1639509508Medicaid