Provider Demographics
NPI:1043734650
Name:AVERY, TIFFANY (LAC)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:AVERY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:AVERY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:3303 E BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3303 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2738
Practice Address - Country:US
Practice Address - Phone:480-269-2656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-26
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1090171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1090Medicaid
AZ1090OtherTIRWEST - VETERANS