Provider Demographics
NPI:1609357177
Name:FONDREN, TIFFANY MONET (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:MONET
Last Name:FONDREN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:DR
Other - First Name:TIFFANY
Other - Middle Name:MONET
Other - Last Name:LAMBERT-LUCAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:201 CAROLINA POINT PKWY
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-6554
Mailing Address - Country:US
Mailing Address - Phone:864-567-2683
Mailing Address - Fax:
Practice Address - Street 1:150 GENTILLY BLVD
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-8522
Practice Address - Country:US
Practice Address - Phone:678-719-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-23
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT013610225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist