Healthcare Provider Details

I. General information

NPI: 1528011699
Provider Name (Legal Business Name): TIFFANY BOND CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 N MORLEY ST SUITE NUMBER 105
MOBERLY MO
65270-2556
US

IV. Provider business mailing address

26602 STATE HIGHWAY T
EXCELLO MO
65247-2162
US

V. Phone/Fax

Practice location:
  • Phone: 660-263-5787
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2003015716
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: