Provider Demographics
NPI:1992947469
Name:DIAZ, TAMMY ANN
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:ANN
Last Name:DIAZ
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 1:12 HAROLD ST
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-2102
Mailing Address - Country:US
Mailing Address - Phone:631-431-1034
Mailing Address - Fax:631-758-0284
Practice Address - Street 1:12 HAROLD ST
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-2102
Practice Address - Country:US
Practice Address - Phone:631-431-1034
Practice Address - Fax:631-758-0284
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1345267174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist