Provider Demographics
NPI:1669784302
Name:MANDIGO, TAMMY REBECCA
Entity type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:REBECCA
Last Name:MANDIGO
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 1:254 HEATH ROAD
Mailing Address - Street 2:TAMMY MANDIGO
Mailing Address - City:SOUTH HERO
Mailing Address - State:VT
Mailing Address - Zip Code:05486-4900
Mailing Address - Country:US
Mailing Address - Phone:802-730-8095
Mailing Address - Fax:
Practice Address - Street 1:38 WHIPPLE RD
Practice Address - Street 2:
Practice Address - City:SOUTH HERO
Practice Address - State:VT
Practice Address - Zip Code:05486-4900
Practice Address - Country:US
Practice Address - Phone:802-732-4020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-10
Last Update Date:2010-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT025.0008399385HR2065X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child