Healthcare Provider Details

I. General information

NPI: 1437922135
Provider Name (Legal Business Name): TIFFANY MCMULLEN MASTERS DEGREE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2023
Last Update Date: 11/03/2023
Certification Date: 10/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 CENTENARY BLVD STE 312
SHREVEPORT LA
71104-3358
US

IV. Provider business mailing address

2620 CENTENARY BLVD STE 312
SHREVEPORT LA
71104-3358
US

V. Phone/Fax

Practice location:
  • Phone: 318-681-9935
  • Fax:
Mailing address:
  • Phone: 318-272-0299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: