Provider Demographics
NPI:1194519546
Name:SECOR, TAMMIE S
Entity type:Individual
Prefix:
First Name:TAMMIE
Middle Name:S
Last Name:SECOR
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49264 CHURCHILL ST
Mailing Address - Street 2:
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071-8888
Mailing Address - Country:US
Mailing Address - Phone:269-366-5627
Mailing Address - Fax:
Practice Address - Street 1:49264 CHURCHILL ST
Practice Address - Street 2:
Practice Address - City:MATTAWAN
Practice Address - State:MI
Practice Address - Zip Code:49071-8888
Practice Address - Country:US
Practice Address - Phone:269-366-5627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI895195133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered