Provider Demographics
NPI:1952090698
Name:BOGAN, TAMMY
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:BOGAN
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 1:2012 LANTERN DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:GA
Mailing Address - Zip Code:30549
Mailing Address - Country:US
Mailing Address - Phone:404-210-8681
Mailing Address - Fax:
Practice Address - Street 1:2012 LANTERN DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:GA
Practice Address - Zip Code:30549
Practice Address - Country:US
Practice Address - Phone:404-210-8681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver