Provider Demographics
NPI:1629448964
Name:TIFFANY DOUGLAS
Entity Type:Organization
Organization Name:TIFFANY DOUGLAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP/ PRIMARY CARE PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-423-3561
Mailing Address - Street 1:1 SOLDIERS FIELD PARK
Mailing Address - Street 2:APT 501
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02163-1722
Mailing Address - Country:US
Mailing Address - Phone:864-423-3561
Mailing Address - Fax:
Practice Address - Street 1:1 SOLDIERS FIELD PARK
Practice Address - Street 2:APT 501
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02163-1722
Practice Address - Country:US
Practice Address - Phone:864-423-3561
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2299504261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center