Provider Demographics
NPI:1275725319
Name:TIFFANY, MARANDA S (MPT)
Entity Type:Individual
Prefix:
First Name:MARANDA
Middle Name:S
Last Name:TIFFANY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 WOODFORD LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-7927
Mailing Address - Country:US
Mailing Address - Phone:386-597-5869
Mailing Address - Fax:
Practice Address - Street 1:26 N BEACH ST
Practice Address - Street 2:SUITE B
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5663
Practice Address - Country:US
Practice Address - Phone:386-673-0201
Practice Address - Fax:386-677-8143
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT22240225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY04EAOtherBCBS NON-PAR
FLY04EAOtherBCBS NON-PAR