Healthcare Provider Details

I. General information

NPI: 1548751589
Provider Name (Legal Business Name): TIFFANY ROE HANKLA AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2018
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 BOULEVARD SQ STE B
WAYCROSS GA
31501
US

IV. Provider business mailing address

1705 BOULEVARD SQ STE B
WAYCROSS GA
31501-8032
US

V. Phone/Fax

Practice location:
  • Phone: 912-284-9200
  • Fax:
Mailing address:
  • Phone: 912-284-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAUD004130
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberAUD004130
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: