Healthcare Provider Details

I. General information

NPI: 1275445462
Provider Name (Legal Business Name): TIFFANY NICOLE HOLLEY MPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 E ROBINSON AVE
GROVETOWN GA
30813-2132
US

IV. Provider business mailing address

526 E ROBINSON AVE
GROVETOWN GA
30813-2132
US

V. Phone/Fax

Practice location:
  • Phone: 706-962-8850
  • Fax:
Mailing address:
  • Phone: 706-962-8850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberCO097690
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: