Healthcare Provider Details

I. General information

NPI: 1164856837
Provider Name (Legal Business Name): MISS TIFFANY C GODWIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2013
Last Update Date: 08/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 NORTH 36TH STREET
MEXICO BEACH FL
32410-0353
US

IV. Provider business mailing address

PO BOX 353
PORT SAINT JOE FL
32457-0353
US

V. Phone/Fax

Practice location:
  • Phone: 850-991-0199
  • Fax:
Mailing address:
  • Phone: 850-991-0199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: