Healthcare Provider Details

I. General information

NPI: 1851889976
Provider Name (Legal Business Name): TAMMI FULGHAM LAWRENCE P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2018
Last Update Date: 04/21/2024
Certification Date: 04/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 PARKWAY MNR
HERNANDO MS
38632-1644
US

IV. Provider business mailing address

146 PARKWAY MNR
HERNANDO MS
38632-1644
US

V. Phone/Fax

Practice location:
  • Phone: 256-694-1200
  • Fax:
Mailing address:
  • Phone: 256-694-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA00435
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3541
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: