Healthcare Provider Details

I. General information

NPI: 1245967389
Provider Name (Legal Business Name): TIFFANY MARTIN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2022
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 S HABANA AVE STE 340
TAMPA FL
33609-4191
US

IV. Provider business mailing address

508 S HABANA AVE STE 340
TAMPA FL
33609-4191
US

V. Phone/Fax

Practice location:
  • Phone: 813-873-7367
  • Fax: 813-875-9722
Mailing address:
  • Phone: 813-873-7367
  • Fax: 813-875-9722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number11020622
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: