1457486805 NPI number — TIFFANY MARIE REDMOND PA-C, LPC

Table of content: TIFFANY MARIE REDMOND PA-C, LPC (NPI 1457486805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457486805 NPI number — TIFFANY MARIE REDMOND PA-C, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REDMOND
Provider First Name:
TIFFANY
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C, LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457486805
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2561 S 1560 W STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODS CROSS
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84087-2361
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-505-0821
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3935 N 75 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HYDE PARK
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84318-4111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-994-2665
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/23/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  7615 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 10279349 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)