1821749458 NPI number — MRS. TIFFANY MARTIN LM, CPM

Table of content: (NPI 1780231506)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821749458 NPI number — MRS. TIFFANY MARTIN LM, CPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
TIFFANY
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LM, CPM
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:
1821749458
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1140 HYACINTH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT AUGUSTINE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32092-2432
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-954-7937
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5A SANCHEZ AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST AUGUSTINE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32084-3284
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-900-0900
Provider Business Practice Location Address Fax Number:
904-506-2012
Provider Enumeration Date:
01/14/2022

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: 176B00000X , with the licence number:  428 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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