Healthcare Provider Details

I. General information

NPI: 1487967618
Provider Name (Legal Business Name): DEIDRE COBB TIFT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 07/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 GARDEN CIR
HINESVILLE GA
31313-4421
US

IV. Provider business mailing address

210 GARDEN CIR
HINESVILLE GA
31313-4421
US

V. Phone/Fax

Practice location:
  • Phone: 912-977-4643
  • Fax: 912-369-6530
Mailing address:
  • Phone: 912-977-4643
  • Fax: 912-369-6530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberRN081939
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberMSW003123
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN081939
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: