Healthcare Provider Details

I. General information

NPI: 1750557062
Provider Name (Legal Business Name): TIFFANY NICOLE BAILEY P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIFFANY NICOLE MARTIN

II. Dates (important events)

Enumeration Date: 05/06/2008
Last Update Date: 10/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2603 KENTUCKY AVE SUITE 303
PADUCAH KY
42003-3814
US

IV. Provider business mailing address

PO BOX 7626
PADUCAH KY
42002-7626
US

V. Phone/Fax

Practice location:
  • Phone: 270-443-2900
  • Fax: 270-443-7122
Mailing address:
  • Phone: 270-443-2900
  • Fax: 270-443-7122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1127
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1127
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: