Healthcare Provider Details

I. General information

NPI: 1376851378
Provider Name (Legal Business Name): TAMMIE L GOULART R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TAMMIE L. MURPHY

II. Dates (important events)

Enumeration Date: 09/24/2010
Last Update Date: 09/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4290 POLK AVENUE
SAN DIEGO CA
92105-1524
US

IV. Provider business mailing address

4290 POLK AVENUE
SAN DIEGO CA
92105-1524
US

V. Phone/Fax

Practice location:
  • Phone: 619-563-0250
  • Fax: 619-563-0293
Mailing address:
  • Phone: 619-563-0507
  • Fax: 619-563-0015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN782060
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: