Provider Demographics
NPI:1073988598
Name:KING, TAMARA LYNN
Entity type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:LYNN
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1 WYOMING ST
Mailing Address - Street 2:BERRY BUILDING, GROUND FLOOR
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2722
Mailing Address - Country:US
Mailing Address - Phone:937-208-2516
Mailing Address - Fax:937-208-6124
Practice Address - Street 1:1 WYOMING ST
Practice Address - Street 2:BERRY BUILDING, GROUND FLOOR
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2722
Practice Address - Country:US
Practice Address - Phone:937-208-2516
Practice Address - Fax:937-208-6124
Is Sole Proprietor?:No
Enumeration Date:2015-12-09
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN282583163WP1700X, 163WW0101X
OHCOA.18661-NP363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163WP1700XNursing Service ProvidersRegistered NursePerinatal
No163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0156508Medicaid
OH0156508Medicaid