Healthcare Provider Details

I. General information

NPI: 1750148813
Provider Name (Legal Business Name): TIFFANIE WEEKLEY RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2716 FORUM BLVD STE 3
COLUMBIA MO
65203-5450
US

IV. Provider business mailing address

18911 CC HWY
BLACKWATER MO
65322-2258
US

V. Phone/Fax

Practice location:
  • Phone: 573-447-6155
  • Fax:
Mailing address:
  • Phone: 660-621-3022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-42324
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number2008004537
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: