Provider Demographics
NPI:1750750949
Name:OLDHAM, TAMMY
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:OLDHAM
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 1:247 TIOGA STREET
Mailing Address - Street 2:
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901
Mailing Address - Country:US
Mailing Address - Phone:570-724-2424
Mailing Address - Fax:570-724-2425
Practice Address - Street 1:247 TIOGA ST
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-6776
Practice Address - Country:US
Practice Address - Phone:570-724-2424
Practice Address - Fax:570-724-2425
Is Sole Proprietor?:No
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA462809249171W00000X, 172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No172A00000XOther Service ProvidersDriver