Provider Demographics
NPI:1134785769
Name:BENNETT, TIFFANY SOPHIA
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:SOPHIA
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:SOPHIA
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:304 S PARKWAY ST
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-5913
Mailing Address - Country:US
Mailing Address - Phone:626-642-1560
Mailing Address - Fax:662-200-5994
Practice Address - Street 1:304 S PARKWAY ST
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-5913
Practice Address - Country:US
Practice Address - Phone:662-642-1560
Practice Address - Fax:662-200-5994
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903343363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNT12267AOtherMEDICARE
MS900162OtherMEDICARE
MSPENDINGMedicaid
TNQ054688Medicaid