Basic Information
Provider Information
NPI: 1003002403
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LOPEZ
FirstName: TAMMY
MiddleName: A
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 361 E MAIN ST
Address2:  
City: OTHELLO
State: WA
PostalCode: 993441055
CountryCode: US
TelephoneNumber: 5094883346
FaxNumber: 5094883348
Practice Location
Address1: 361 E MAIN ST
Address2:  
City: OTHELLO
State: WA
PostalCode: 993441055
CountryCode: US
TelephoneNumber: 5094883346
FaxNumber: 5094883348
Other Information
ProviderEnumerationDate: 09/19/2007
LastUpdateDate: 09/19/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225700000XMA000023442WAY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist 

No ID Information.


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