Provider Demographics
NPI:1700149614
Name:BENNETT, TAMMY ROXANNE (RN)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:ROXANNE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 PEA RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-7824
Mailing Address - Country:US
Mailing Address - Phone:601-347-2643
Mailing Address - Fax:
Practice Address - Street 1:626 CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:BOGALUSA
Practice Address - State:LA
Practice Address - Zip Code:70427-3319
Practice Address - Country:US
Practice Address - Phone:985-732-6615
Practice Address - Fax:985-732-6621
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN078048163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health