Provider Demographics
NPI:1548254097
Name:SMITH, TAMMY R (FNP-BC)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:R
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:SCARBRO
Mailing Address - State:WV
Mailing Address - Zip Code:25917-0337
Mailing Address - Country:US
Mailing Address - Phone:304-469-2905
Mailing Address - Fax:304-465-3180
Practice Address - Street 1:410 MAIN STREET
Practice Address - Street 2:GULF FAMILY PRACTICE
Practice Address - City:SOPHIA
Practice Address - State:WV
Practice Address - Zip Code:25921-1304
Practice Address - Country:US
Practice Address - Phone:304-683-4304
Practice Address - Fax:304-683-4307
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV56022363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000221Medicaid
WV3810000221Medicaid
WV15905Medicare PIN