Provider Demographics
NPI:1124314026
Name:EDWALL, TIFFANY (DC)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:EDWALL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-3817
Mailing Address - Country:US
Mailing Address - Phone:727-528-1133
Mailing Address - Fax:727-527-3750
Practice Address - Street 1:4247 W KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-2230
Practice Address - Country:US
Practice Address - Phone:813-289-5575
Practice Address - Fax:813-289-5565
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 100055111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor