1497070585 NPI number — TAMMY LEANNE RAY JERNIGAN ARNP

Table of content: TAMMY LEANNE RAY JERNIGAN ARNP (NPI 1497070585)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497070585 NPI number — TAMMY LEANNE RAY JERNIGAN ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JERNIGAN
Provider First Name:
TAMMY
Provider Middle Name:
LEANNE RAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
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:
1497070585
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2340 BAYOU BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32503-5008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-512-8816
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4501 N DAVIS HWY STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32503-2724
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-416-4960
Provider Business Practice Location Address Fax Number:
850-416-4961
Provider Enumeration Date:
03/31/2010

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:  1563722 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0026279-00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 111663100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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