Provider Demographics
NPI:1083321293
Name:PONTIOUS, TIFFANY NICOLE
Entity Type:Individual
Prefix:MISS
First Name:TIFFANY
Middle Name:NICOLE
Last Name:PONTIOUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8308 OHIO RIVER RD
Mailing Address - Street 2:
Mailing Address - City:WHEELERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45694-1714
Mailing Address - Country:US
Mailing Address - Phone:740-529-1201
Mailing Address - Fax:
Practice Address - Street 1:8308 OHIO RIVER RD
Practice Address - Street 2:
Practice Address - City:WHEELERSBURG
Practice Address - State:OH
Practice Address - Zip Code:45694-1714
Practice Address - Country:US
Practice Address - Phone:740-529-1201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-28
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH843687127Medicaid