Provider Demographics
NPI:1144354135
Name:SHALLIS, TAMMY
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:SHALLIS
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 1:231 OCEAN JASPER DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-8092
Mailing Address - Country:US
Mailing Address - Phone:904-826-7007
Mailing Address - Fax:
Practice Address - Street 1:231 OCEAN JASPER DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-8092
Practice Address - Country:US
Practice Address - Phone:904-826-7007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT080347163W00000X
FLRN9262129163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse