Provider Demographics
NPI:1467971325
Name:MOON, TIFFANY GRAY (WHNP-BC)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:GRAY
Last Name:MOON
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 LEIGH ST
Mailing Address - Street 2:
Mailing Address - City:EDENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27932-1657
Mailing Address - Country:US
Mailing Address - Phone:252-562-4410
Mailing Address - Fax:
Practice Address - Street 1:198 NC HIGHWAY 45 N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NC
Practice Address - Zip Code:27962-9232
Practice Address - Country:US
Practice Address - Phone:252-791-3119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5009694363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health