Provider Demographics
NPI:1063906501
Name:MCMULLION, TIFFANY NICHELLE
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICHELLE
Last Name:MCMULLION
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 AZALEA DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2417
Mailing Address - Country:US
Mailing Address - Phone:229-415-8814
Mailing Address - Fax:
Practice Address - Street 1:6310 ANVIL RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32277-3529
Practice Address - Country:US
Practice Address - Phone:229-415-8814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health