Provider Demographics
NPI:1114439338
Name:TIPTON, ANITA
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:TIPTON
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 1:2970 CABBAGE HAMMOCK RD
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-0561
Mailing Address - Country:US
Mailing Address - Phone:904-209-7043
Mailing Address - Fax:
Practice Address - Street 1:2970 CABBAGE HAMMOCK RD
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-0561
Practice Address - Country:US
Practice Address - Phone:904-209-7043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-27
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL233893171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator