Provider Demographics
NPI:1760678106
Name:NICHOLS, TIFFANI MARIA (DO)
Entity Type:Individual
Prefix:DR
First Name:TIFFANI
Middle Name:MARIA
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TIFFANI
Other - Middle Name:MARIA
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:716 SPRING ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WISE
Mailing Address - State:VA
Mailing Address - Zip Code:24293
Mailing Address - Country:US
Mailing Address - Phone:276-328-8910
Mailing Address - Fax:276-328-4318
Practice Address - Street 1:716 SPRING ST
Practice Address - Street 2:SUITE 204
Practice Address - City:WISE
Practice Address - State:VA
Practice Address - Zip Code:24293
Practice Address - Country:US
Practice Address - Phone:276-328-8910
Practice Address - Fax:276-328-4318
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102202126207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00739464OtherRR MEDICARE
KY7100077080Medicaid
VA1760678106Medicaid
P00739464OtherRR MEDICARE
VA1760678106Medicaid