Basic Information
| Provider Information | |||||||||
| NPI: | 1265439384 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | TAMELA | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | C-FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 N 5TH ST | ||||||||
| Address2: | |||||||||
| City: | IRONTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456381578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405323534 | ||||||||
| FaxNumber: | 7405324859 | ||||||||
| Practice Location | |||||||||
| Address1: | 10777 COUNTY ROAD 107 | ||||||||
| Address2: | |||||||||
| City: | PROCTORVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456698130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403020541 | ||||||||
| FaxNumber: | 7408670017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2005 | ||||||||
| LastUpdateDate: | 01/29/2018 | ||||||||
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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 | 37484 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | COA.05133-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2315300 | 05 | OH | MEDICAID | 7102062000 | 05 | WV | MEDICAID | 78012846 | 05 | KY | MEDICAID |