Provider Demographics
NPI:1295171361
Name:MOULTERIE, TIFFANY NICOLE (DC)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICOLE
Last Name:MOULTERIE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-2958
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1660 BLANDING BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-1835
Practice Address - Country:US
Practice Address - Phone:904-389-3811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-16
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 10787111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008954000Medicaid
FL008954000Medicaid