Healthcare Provider Details

I. General information

NPI: 1043716582
Provider Name (Legal Business Name): TAMMY LYNN DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 04/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 OPERA HOUSE RD
MADRID NM
87010-9760
US

IV. Provider business mailing address

PO BOX 845
CERRILLOS NM
87010-0845
US

V. Phone/Fax

Practice location:
  • Phone: 505-225-4092
  • Fax:
Mailing address:
  • Phone: 505-225-4092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: