Provider Demographics
NPI:1154953099
Name:GORMAN, TAMARA D
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:D
Last Name:GORMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:D
Other - Last Name:METTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3560 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-5540
Mailing Address - Country:US
Mailing Address - Phone:812-235-8496
Mailing Address - Fax:812-478-1540
Practice Address - Street 1:3560 S 4TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-5540
Practice Address - Country:US
Practice Address - Phone:812-235-8496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-09
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28249915A163W00000X
IN71009794A363L00000X
IL209027013363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner