1689127615 NPI number — TAMMY JUSTICE OFFICE MANAGER

Table of content: TAMMY JUSTICE OFFICE MANAGER (NPI 1689127615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689127615 NPI number — TAMMY JUSTICE OFFICE MANAGER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JUSTICE
Provider First Name:
TAMMY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OFFICE MANAGER
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:
1689127615
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
05/29/2019
NPI Reactivation Date:
04/26/2022

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 BRYAN ST
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
HUNTINGDON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16652-2413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-643-6300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 BRYAN ST
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
HUNTINGDON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16652-2413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-643-6300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/26/2016

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: 164W00000X , with the licence number:  PN097247L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1740463470 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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