Provider Demographics
NPI:1033870571
Name:TUCKER OLDHAM, TIFFANY NICOLE (CT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICOLE
Last Name:TUCKER OLDHAM
Suffix:
Gender:F
Credentials:CT
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 261
Mailing Address - Street 2:
Mailing Address - City:GOLDSTON
Mailing Address - State:NC
Mailing Address - Zip Code:27252-0261
Mailing Address - Country:US
Mailing Address - Phone:919-935-7485
Mailing Address - Fax:
Practice Address - Street 1:110 FIELDS DR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-5066
Practice Address - Country:US
Practice Address - Phone:919-777-9005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-06
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist