Provider Demographics
NPI:1477668556
Name:PATTERSON, TIFFANY P (MOT, OTRL)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:P
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:MOT, OTRL
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:P
Other - Last Name:HARRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MOT, OTRL
Mailing Address - Street 1:PO BOX 40767
Mailing Address - Street 2:CREDENTIALING DEPARTMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-0767
Mailing Address - Country:US
Mailing Address - Phone:904-376-3707
Mailing Address - Fax:904-391-5807
Practice Address - Street 1:14985 OLD SAINT AUGUSTINE RD UNIT 106
Practice Address - Street 2:CREDENTIALING DEPARTMENT
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-9478
Practice Address - Country:US
Practice Address - Phone:904-288-9491
Practice Address - Fax:904-288-9698
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT10452225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00672041OtherRR MEDICARE
FLAJ452ZMedicare PIN