Provider Demographics
NPI:1447445374
Name:FETZER, TAMMY LYNN
Entity type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:LYNN
Last Name:FETZER
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:TAMMY
Other - Middle Name:LYNN
Other - Last Name:BATES-FETZER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:102 E GORE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73501-3025
Mailing Address - Country:US
Mailing Address - Phone:580-353-0334
Mailing Address - Fax:
Practice Address - Street 1:102 E GORE BLVD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-3025
Practice Address - Country:US
Practice Address - Phone:580-353-0334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1706225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK73-6029956Medicaid