=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033656228
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAMIKA WELCH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2017
-----------------------------------------------------
Last Update Date | 01/25/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 209 E WATER ST
-----------------------------------------------------
City | CASSOPOLIS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49031-1357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-445-2417
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 209 E WATER ST
-----------------------------------------------------
City | CASSOPOLIS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49031-1357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-445-2417
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 4703114223
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------