1548492267 NPI number — TIFFANY CHARON MOSBY LPN

Table of content: TIFFANY CHARON MOSBY LPN (NPI 1548492267)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548492267 NPI number — TIFFANY CHARON MOSBY LPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOSBY
Provider First Name:
TIFFANY
Provider Middle Name:
CHARON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPN
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:
1548492267
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
911 2ND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNDS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62964-1344
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-234-1923
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
508 FULTON STREET
Provider Second Line Business Practice Location Address:
DURHAM VA MEDICAL CENTER
Provider Business Practice Location Address City Name:
DURHAM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-416-8001
Provider Business Practice Location Address Fax Number:
919-286-6875
Provider Enumeration Date:
08/13/2009

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: 164W00000X , with the licence number:  0002075837 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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