1588202485 NPI number — MISS TIFFANY MICHELLE STARKS LMT

Table of content: MISS TIFFANY MICHELLE STARKS LMT (NPI 1588202485)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588202485 NPI number — MISS TIFFANY MICHELLE STARKS LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STARKS
Provider First Name:
TIFFANY
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
LMT
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:
1588202485
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
09/24/2020
NPI Reactivation Date:
10/21/2020

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 COUNTRY CLUB DR APT 72
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW ALBANY
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47150-4145
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-561-4569
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
757 E LEWIS AND CLARK PKWY STE 342
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARKSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47131-6078
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-561-4569
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/11/2019

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: 225700000X , with the licence number:  MT21906841 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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