Provider Demographics
NPI:1952959108
Name:DAMON, TAMARA J
Entity Type:Individual
Prefix:MS
First Name:TAMARA
Middle Name:J
Last Name:DAMON
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 1:1152 W HORSESHOE AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-5266
Mailing Address - Country:US
Mailing Address - Phone:480-307-4717
Mailing Address - Fax:
Practice Address - Street 1:1152 W HORSESHOE AVE
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-5266
Practice Address - Country:US
Practice Address - Phone:480-307-4717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-30
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86063970136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered