Provider Demographics
NPI:1912291089
Name:MATTINGLY, TIFFANY NICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:NICOLE
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 RIVERLYN TER
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-2831
Mailing Address - Country:US
Mailing Address - Phone:479-883-9058
Mailing Address - Fax:
Practice Address - Street 1:1500 DODSON AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-5182
Practice Address - Country:US
Practice Address - Phone:479-441-2694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-06
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-88672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry