1134616824 NPI number — MS. TIFFANY ANN EATON FNP

Table of content: CHARLES W WALLACE MD (NPI 1780652792)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134616824 NPI number — MS. TIFFANY ANN EATON FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EATON
Provider First Name:
TIFFANY
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
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:
1134616824
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
248 GREENLAW DISTRICT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEER ISLE
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04627-3551
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-348-5668
Provider Business Mailing Address Fax Number:
207-374-3970

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
57 WATER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLUE HILL
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-374-3995
Provider Business Practice Location Address Fax Number:
207-374-3970
Provider Enumeration Date:
04/18/2018

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: 363LF0000X , with the licence number:  CNP181154 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1134616824 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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