Provider Demographics
NPI:1558914911
Name:WOOLUM, TIFFANY
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:WOOLUM
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 1:7327 LODGETOWN RD
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:GA
Mailing Address - Zip Code:31779-6563
Mailing Address - Country:US
Mailing Address - Phone:229-393-6954
Mailing Address - Fax:
Practice Address - Street 1:919 S BROAD ST
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6114
Practice Address - Country:US
Practice Address - Phone:229-584-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN195846363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily