1073045241 NPI number — MS. TIFFANY ANN MULLIN I CP60969079

Table of content: MS. TIFFANY ANN MULLIN I CP60969079 (NPI 1073045241)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073045241 NPI number — MS. TIFFANY ANN MULLIN I CP60969079

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MULLIN
Provider First Name:
TIFFANY
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
I
Provider Credential Text:
CP60969079
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:
1073045241
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 W MISSION AVE STE 106
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99201-2347
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-474-1148
Provider Business Mailing Address Fax Number:
833-899-5113

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 W MISSION AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99201-2344
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-474-1148
Provider Business Practice Location Address Fax Number:
833-899-5113
Provider Enumeration Date:
03/28/2017

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: 101YA0400X , with the licence number:  CP60969079 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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