Basic Information
| Provider Information | |||||||||
| NPI: | 1780878736 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SARMIENTO | ||||||||
| FirstName: | TAMMY | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 530 NE GLEN OAK AVE | ||||||||
| Address2: | 4TH FLOOR NORTHBUILDING- PALLIATIVE CARE SERVICES | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616370001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096241818 | ||||||||
| FaxNumber: | 3096248820 | ||||||||
| Practice Location | |||||||||
| Address1: | 530 NE GLEN OAK AVE | ||||||||
| Address2: | 4TH FLOOR NORTHBUILDING- PALLIATIVE CARE SERVICES | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616370001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096241818 | ||||||||
| FaxNumber: | 3096248820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2007 | ||||||||
| LastUpdateDate: | 04/30/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209-006726 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 809840 | 01 | IL | MEDICARE GROUP # | OTHER | CA4079 | 01 | IL | RR MEDICARE GROUP PTAN | OTHER | P00680131 | 01 | IL | RR MEDICARE MEMBER PTAN | OTHER |