Provider Demographics
NPI:1699104315
Name:LATTIMORE, TIFFANY L (PA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:L
Last Name:LATTIMORE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:L
Other - Last Name:MEDLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:616-486-6702
Practice Address - Street 1:8354 100TH AVE
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:MI
Practice Address - Zip Code:49346-8344
Practice Address - Country:US
Practice Address - Phone:231-972-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006795363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant