Provider Demographics
NPI:1952450694
Name:FONAGY, TIFFANY LYN (ATC, PES)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LYN
Last Name:FONAGY
Suffix:
Gender:F
Credentials:ATC, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4175 MOUNTAIN VIEW RD APT 109
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17050-7628
Mailing Address - Country:US
Mailing Address - Phone:717-732-1819
Mailing Address - Fax:
Practice Address - Street 1:75 EVELYN DR
Practice Address - Street 2:
Practice Address - City:MILLERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17061-1258
Practice Address - Country:US
Practice Address - Phone:717-692-4708
Practice Address - Fax:717-692-5464
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARTO0000152255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer