Healthcare Provider Details

I. General information

NPI: 1467453993
Provider Name (Legal Business Name): TAMMY LYNN WIETIES OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 02/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 W MEFFORD ST
ROBINSON IL
62454-1065
US

IV. Provider business mailing address

905 W MEFFORD ST
ROBINSON IL
62454-1065
US

V. Phone/Fax

Practice location:
  • Phone: 618-544-3525
  • Fax: 618-544-3261
Mailing address:
  • Phone: 618-544-3525
  • Fax: 618-544-3261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046008222
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: