Healthcare Provider Details

I. General information

NPI: 1255949426
Provider Name (Legal Business Name): TAMMY LYNN EASTRIDGE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E NIZHONI BLVD
GALLUP NM
87301-5748
US

IV. Provider business mailing address

6283 TEASDALE RD
CHARLESTON MS
38921-9761
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax:
Mailing address:
  • Phone: 662-614-0808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number862849
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: