Provider Demographics
NPI:1104522069
Name:WESTON, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:WESTON
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:PO BOX 1890
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72018-1890
Mailing Address - Country:US
Mailing Address - Phone:501-778-4960
Mailing Address - Fax:501-778-4968
Practice Address - Street 1:640 MLK BLVD
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-2632
Practice Address - Country:US
Practice Address - Phone:501-467-8275
Practice Address - Fax:501-467-8145
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR5259225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist