Provider Demographics
NPI:1770770117
Name:GRANT, TIFFANI L (LD)
Entity type:Individual
Prefix:MISS
First Name:TIFFANI
Middle Name:L
Last Name:GRANT
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:P.O. BOX 24146
Mailing Address - Street 2:UNIVERSITY PHYSICIANS, PLLC
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-4146
Mailing Address - Country:US
Mailing Address - Phone:601-984-5660
Mailing Address - Fax:601-984-6870
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:DEPARTMENT OF MEDICINE/DIVISION OF GENERAL INTERNAL MED
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1248133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS512I710005Medicare PIN