MEDICARE: TAMMY M GRISHAM NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	9203521	FL

General Provider Information

NPI Number	:	1619489473
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMMY M GRISHAM NP-C

Provider Business Mailing Address
First Line	:	714 NW LEONARDO CIR
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34986-4354
Country	:	US
Telephone Number	:	954-448-3913
Fax Number	:

Provider Business Practice Location Address
First Line	:	714 NW LEONARDO CIR
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34986-4354
Country	:	US
Telephone Number	:	954-448-3913
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2017
Last Update Date	:	06/18/2024

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