Healthcare Provider Details

I. General information

NPI: 1760120877
Provider Name (Legal Business Name): TAMMY DIANE DONNICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2022
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 SE OCEAN BLVD STE 103
STUART FL
34996-3332
US

IV. Provider business mailing address

2100 SE OCEAN BLVD STE 103
STUART FL
34996-3332
US

V. Phone/Fax

Practice location:
  • Phone: 772-247-7856
  • Fax: 772-247-7854
Mailing address:
  • Phone: 772-247-7856
  • Fax: 772-247-7854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN11019886
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: