Healthcare Provider Details

I. General information

NPI: 1487589248
Provider Name (Legal Business Name): TAMMY GRIM HAIR LOSS PRACTIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 W 2ND ST STE 110
WASHINGTON MO
63090-2147
US

IV. Provider business mailing address

209 W 2ND ST STE 110
WASHINGTON MO
63090-2147
US

V. Phone/Fax

Practice location:
  • Phone: 636-286-6717
  • Fax: 636-286-6717
Mailing address:
  • Phone: 636-286-6717
  • Fax: 636-286-6717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number090550
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: