Provider Demographics
NPI:1528134129
Name:DAVIS, TAMMY LYNN
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:LYNN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:LYNN
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:324 W SUPERIOR ST STE 620
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1723
Mailing Address - Country:US
Mailing Address - Phone:218-591-2648
Mailing Address - Fax:
Practice Address - Street 1:324 W SUPERIOR ST STE 620
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1723
Practice Address - Country:US
Practice Address - Phone:218-606-1797
Practice Address - Fax:651-952-0039
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3238363L00000X
MNR147980-5363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN591804900Medicaid
MN591804900Medicaid