Provider Demographics
NPI:1841816238
Name:SOUTHWARD, TAMMY ALBERTA
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:ALBERTA
Last Name:SOUTHWARD
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 1:5213 BRITTON RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-4298
Mailing Address - Country:US
Mailing Address - Phone:817-807-1979
Mailing Address - Fax:
Practice Address - Street 1:5213 BRITTON RIDGE LN
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-4298
Practice Address - Country:US
Practice Address - Phone:817-807-1979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX124833164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse