Provider Demographics
NPI:1427626290
Name:PURNELL, TAMARA MARIA
Entity type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:MARIA
Last Name:PURNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12618 ROSENCRANS DR
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-1212
Mailing Address - Country:US
Mailing Address - Phone:302-725-9084
Mailing Address - Fax:
Practice Address - Street 1:12814 SHANK FARM WAY STE D
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-2949
Practice Address - Country:US
Practice Address - Phone:302-725-9084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEMT-0015118225700000X
MDR03340225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist