Basic Information
| Provider Information | |||||||||
| NPI: | 1366096034 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FUSILIER | ||||||||
| FirstName: | TAMMY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3460 OLD WASHINGTON RD | ||||||||
| Address2: | STE 203A | ||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206023243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016380602 | ||||||||
| FaxNumber: | 3016387558 | ||||||||
| Practice Location | |||||||||
| Address1: | 3460 OLD WASHINGTON RD STE 203A | ||||||||
| Address2: | |||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206023243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016380602 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2019 | ||||||||
| LastUpdateDate: | 04/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | R215486 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.