Provider Demographics
NPI:1043716582
Name:DAVIS, TAMMY LYNN
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:LYNN
Last Name:DAVIS
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:PO BOX 845
Mailing Address - Street 2:
Mailing Address - City:CERRILLOS
Mailing Address - State:NM
Mailing Address - Zip Code:87010-0845
Mailing Address - Country:US
Mailing Address - Phone:505-225-4092
Mailing Address - Fax:
Practice Address - Street 1:1 OPERA HOUSE RD
Practice Address - Street 2:
Practice Address - City:MADRID
Practice Address - State:NM
Practice Address - Zip Code:87010-9760
Practice Address - Country:US
Practice Address - Phone:505-225-4092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education