Provider Demographics
NPI:1447921663
Name:GWIN, TAMMY MARIE
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:MARIE
Last Name:GWIN
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 1:2867 WYOMING DR
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-4443
Mailing Address - Country:US
Mailing Address - Phone:937-532-8533
Mailing Address - Fax:
Practice Address - Street 1:2867 WYOMING DR
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-4443
Practice Address - Country:US
Practice Address - Phone:937-532-8533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist