Provider Demographics
NPI:1902827421
Name:KING, TIFFANY DUMONT (CRNA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DUMONT
Last Name:KING
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2138 PRESIDENTIAL DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314
Mailing Address - Country:US
Mailing Address - Phone:304-561-5967
Mailing Address - Fax:
Practice Address - Street 1:800 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-3351
Practice Address - Country:US
Practice Address - Phone:304-388-2470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV42872367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0067551000Medicaid
WV27-3419445OtherTAX ID
WV8223105Medicare PIN
WV27-3419445OtherTAX ID