1356424758 NPI number — TAMMY L PROUT NP

Table of content: TAMMY L PROUT NP (NPI 1356424758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356424758 NPI number — TAMMY L PROUT NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PROUT
Provider First Name:
TAMMY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356424758
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10601 4TH ST NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87114-2407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-828-3000
Provider Business Mailing Address Fax Number:
505-828-3002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1221 PINE GROVE AVE
Provider Second Line Business Practice Location Address:
EMERGENCY DEPARTMENT
Provider Business Practice Location Address City Name:
PORT HURON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48060-3511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-989-3300
Provider Business Practice Location Address Fax Number:
810-985-2671
Provider Enumeration Date:
10/23/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  4704173662 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)