1235680232 NPI number — MRS. TIFFANY NICOLE WYMORE MA.,PLPC

Table of content: (NPI 1184029811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235680232 NPI number — MRS. TIFFANY NICOLE WYMORE MA.,PLPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WYMORE
Provider First Name:
TIFFANY
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA.,PLPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PELTON
Provider Other First Name:
TIFFANY
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1235680232
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
227 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FESTUS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-931-2700
Provider Business Mailing Address Fax Number:
636-931-5304

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
227 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FESTUS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-931-2700
Provider Business Practice Location Address Fax Number:
636-931-5304
Provider Enumeration Date:
10/14/2016

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:  2016034260 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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