Provider Demographics
NPI:1912057654
Name:JUSTICE, TAMMY
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:JUSTICE
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 1:220 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:IMLAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48444-1045
Mailing Address - Country:US
Mailing Address - Phone:810-388-1200
Mailing Address - Fax:
Practice Address - Street 1:16155 PETZ RD
Practice Address - Street 2:
Practice Address - City:MUSSEY
Practice Address - State:MI
Practice Address - Zip Code:48014-1605
Practice Address - Country:US
Practice Address - Phone:810-388-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant