Provider Demographics
NPI:1669577466
Name:SULLIVAN, TAMMY C
Entity type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:C
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1242 HIGHWAY 100
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37033-1042
Mailing Address - Country:US
Mailing Address - Phone:931-729-9162
Mailing Address - Fax:931-729-9163
Practice Address - Street 1:1242 HIGHWAY 100
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37033-1042
Practice Address - Country:US
Practice Address - Phone:931-729-9162
Practice Address - Fax:931-729-9163
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNI438-046-9362251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH445049Medicaid