Healthcare Provider Details

I. General information

NPI: 1427212356
Provider Name (Legal Business Name): TAMMY LYNN COLON MSOTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TAMMY LYNN BROSHEARS MSOTR/L

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 09/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1169 EASTERN PKWY SUITE 2313
LOUISVILLE KY
40217-1417
US

IV. Provider business mailing address

PO BOX 3276
EVANSVILLE IN
47731-3276
US

V. Phone/Fax

Practice location:
  • Phone: 502-309-9800
  • Fax: 502-309-9797
Mailing address:
  • Phone: 812-473-0181
  • Fax: 812-473-5822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberKY-R3839
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: