Healthcare Provider Details

I. General information

NPI: 1093042236
Provider Name (Legal Business Name): TIFFANY GIBSON FORD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2009
Last Update Date: 11/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3421 MIKE PADGETT HWY
AUGUSTA GA
30906-3815
US

IV. Provider business mailing address

3421 MIKE PADGETT HWY
AUGUSTA GA
30906-3815
US

V. Phone/Fax

Practice location:
  • Phone: 706-432-4858
  • Fax: 706-432-3780
Mailing address:
  • Phone: 706-432-4858
  • Fax: 706-432-3780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN202486
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: