Healthcare Provider Details

I. General information

NPI: 1467899252
Provider Name (Legal Business Name): TAMMY LYNN M.ED., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2013
Last Update Date: 06/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1499 FAIR RD
STATESBORO GA
30458-1683
US

IV. Provider business mailing address

1499 FAIR RD
STATESBORO GA
30458-1683
US

V. Phone/Fax

Practice location:
  • Phone: 912-486-1680
  • Fax:
Mailing address:
  • Phone: 912-486-1680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP006832
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: