Provider Demographics
NPI:1063268753
Name:MAXWELL, TIFFANY HEATHER (PTA)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:HEATHER
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:TIFFANY
Other - Middle Name:HEATHER
Other - Last Name:PACKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:2037 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6430
Mailing Address - Country:US
Mailing Address - Phone:208-529-3355
Mailing Address - Fax:208-529-9581
Practice Address - Street 1:2037 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6430
Practice Address - Country:US
Practice Address - Phone:208-529-3355
Practice Address - Fax:208-529-9581
Is Sole Proprietor?:No
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA5326208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPTA5326OtherPROFESSIONAL LICENSE