Provider Demographics
NPI:1174686786
Name:PANTLE, TAMMY G (PT)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:G
Last Name:PANTLE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:G
Other - Last Name:ROACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:150 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:NY
Mailing Address - Zip Code:14892-1361
Mailing Address - Country:US
Mailing Address - Phone:607-687-2495
Mailing Address - Fax:607-565-2750
Practice Address - Street 1:555 E MARKET ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-3223
Practice Address - Country:US
Practice Address - Phone:607-733-6541
Practice Address - Fax:607-737-1532
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012302-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist