Healthcare Provider Details

I. General information

NPI: 1063492346
Provider Name (Legal Business Name): TIFFANY A LUNT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 GAIL GARDNER WAY STE 100
PRESCOTT AZ
86305-1631
US

IV. Provider business mailing address

PO BOX 10880
PRESCOTT AZ
86304-0880
US

V. Phone/Fax

Practice location:
  • Phone: 928-777-0700
  • Fax: 928-778-5507
Mailing address:
  • Phone: 928-777-0700
  • Fax: 928-778-5507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberN4561
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36387
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: