Provider Demographics
NPI:1316130255
Name:AVINGER, TIFFANY ENGLE (MPT)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:ENGLE
Last Name:AVINGER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MRS
Other - First Name:TIFFANY
Other - Middle Name:ADDERLEY
Other - Last Name:BODENHEIMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:9819 PENNINE CT
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-4841
Mailing Address - Country:US
Mailing Address - Phone:318-671-9034
Mailing Address - Fax:
Practice Address - Street 1:510 E STONER AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4243
Practice Address - Country:US
Practice Address - Phone:318-221-8411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06620174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist