Provider Demographics
NPI:1194938084
Name:DERITO, TAMMY LEE (LPN)
Entity type:Individual
Prefix:MS
First Name:TAMMY
Middle Name:LEE
Last Name:DERITO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2449 BROOK PARK WAY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-9334
Mailing Address - Country:US
Mailing Address - Phone:904-551-2373
Mailing Address - Fax:
Practice Address - Street 1:1601 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-1135
Practice Address - Country:US
Practice Address - Phone:352-374-6047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV23965164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse