Provider Demographics
NPI:1649325150
Name:PETERS, TAMMY M
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:M
Last Name:PETERS
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 1:11639 QUAIL RUN DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-2145
Mailing Address - Country:US
Mailing Address - Phone:239-245-8192
Mailing Address - Fax:239-245-8192
Practice Address - Street 1:11639 QUAIL RUN DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-2145
Practice Address - Country:US
Practice Address - Phone:239-245-8192
Practice Address - Fax:239-245-8192
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL46-8013727279-2174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO3984260001Medicare ID - Type UnspecifiedSUPPLIER NUMBER IN CO