Provider Demographics
NPI:1699350835
Name:MASTIN, TIFFANY (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:MASTIN
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 ASHTONBROOK DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-6705
Mailing Address - Country:US
Mailing Address - Phone:404-922-1985
Mailing Address - Fax:
Practice Address - Street 1:2274 SALEM RD SE STE 1061273
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2097
Practice Address - Country:US
Practice Address - Phone:844-286-8232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN289185163WC1600X, 163WH0200X, 163WI0500X, 163WS0200X, 163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity HealthGroup - Single Specialty
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff DevelopmentGroup - Single Specialty
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
No163WS0200XNursing Service ProvidersRegistered NurseSchool