=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902178999
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAMMARA IVY DAVIS PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2012
-----------------------------------------------------
Last Update Date | 02/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 706 OAK GROVE ST
-----------------------------------------------------
City | MOUNTAIN VIEW
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72560-8601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-269-7059
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2650 PRIM RD
-----------------------------------------------------
City | PRIM
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72130-9526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-615-1555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 1920
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------