1548508203 NPI number — TIFFANY G CLARK FNP-C

Table of content: TIFFANY G CLARK FNP-C (NPI 1548508203)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548508203 NPI number — TIFFANY G CLARK FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARK
Provider First Name:
TIFFANY
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLARK
Provider Other First Name:
TIFFANY
Provider Other Middle Name:
G
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP-C
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1548508203
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
260 SUNNYMEADE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUSTBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24588-3276
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-485-9405
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2215 LANDOVER PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYNCHBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24501-2115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-947-3944
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/30/2013

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:  0024170609 , 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)

  • Identifier: 1548508203 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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