Provider Demographics
NPI:1811066988
Name:PETERSON, TIFFANY LYNN (DC)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LYNN
Last Name:PETERSON
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 1:116 N CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-2401
Mailing Address - Country:US
Mailing Address - Phone:252-451-0039
Mailing Address - Fax:866-801-5246
Practice Address - Street 1:116 N CIRCLE DR
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-2401
Practice Address - Country:US
Practice Address - Phone:252-451-0039
Practice Address - Fax:866-801-5246
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3056111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC085GWOtherBCBS
NC89085GWMedicaid
NC2455686Medicare ID - Type Unspecified
NCU94230Medicare UPIN