Provider Demographics
NPI:1912191313
Name:WICKER, TIFFANY S (CFM)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:S
Last Name:WICKER
Suffix:
Gender:F
Credentials:CFM
Other - Prefix:MS
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:STONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CFM
Mailing Address - Street 1:726 S SCALES ST
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-5330
Mailing Address - Country:US
Mailing Address - Phone:336-342-6474
Mailing Address - Fax:336-342-7660
Practice Address - Street 1:726 S SCALES ST
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-5330
Practice Address - Country:US
Practice Address - Phone:336-342-6474
Practice Address - Fax:336-342-7660
Is Sole Proprietor?:No
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795196Medicaid
NC1740278167OtherNPI