Provider Demographics
NPI:1821749458
Name:MARTIN, TIFFANY (LM, CPM)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 HYACINTH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-2432
Mailing Address - Country:US
Mailing Address - Phone:512-954-7937
Mailing Address - Fax:
Practice Address - Street 1:2301 PARK AVE STE 203
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5558
Practice Address - Country:US
Practice Address - Phone:904-203-8559
Practice Address - Fax:904-592-5282
Is Sole Proprietor?:No
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL428176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife