Provider Demographics
NPI:1124450937
Name:PITTMAN, TIFFANY ANNE (BS)
Entity type:Individual
Prefix:MISS
First Name:TIFFANY
Middle Name:ANNE
Last Name:PITTMAN
Suffix:
Gender:F
Credentials:BS
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 40
Mailing Address - Street 2:
Mailing Address - City:SALUDA
Mailing Address - State:VA
Mailing Address - Zip Code:23149-0040
Mailing Address - Country:US
Mailing Address - Phone:804-758-5250
Mailing Address - Fax:804-758-5183
Practice Address - Street 1:5372B OLD VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:URBANNA
Practice Address - State:VA
Practice Address - Zip Code:23175
Practice Address - Country:US
Practice Address - Phone:804-758-5250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-02
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA17100000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA49-78137Medicaid
VA49-78137Medicaid