Provider Demographics
NPI:1619228996
Name:GRIBBLE, TIFFANY MARIE
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MARIE
Last Name:GRIBBLE
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 1:260 CAGNEY LN APT 319
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-2672
Mailing Address - Country:US
Mailing Address - Phone:920-740-5367
Mailing Address - Fax:
Practice Address - Street 1:260 CAGNEY LN APT 319
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-2672
Practice Address - Country:US
Practice Address - Phone:920-740-5367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1982-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant