Healthcare Provider Details

I. General information

NPI: 1245505478
Provider Name (Legal Business Name): TIFFANY R TONISMAE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E CHESTNUT ST
LOUISVILLE KY
40202-5700
US

IV. Provider business mailing address

625 6TH AVE S STE 340
ST PETERSBURG FL
33701-4619
US

V. Phone/Fax

Practice location:
  • Phone: 502-588-4400
  • Fax:
Mailing address:
  • Phone: 727-767-7903
  • Fax: 727-767-7905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number57470
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberME140511
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberMD70070337
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: