Healthcare Provider Details

I. General information

NPI: 1992433163
Provider Name (Legal Business Name): TIFFANY BOYD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2022
Last Update Date: 08/15/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1161 CHURCH ROAD W
SOUTHAVEN MS
38671
US

IV. Provider business mailing address

1161 CHURCH ROAD W
SOUTHAVEN MS
38671
US

V. Phone/Fax

Practice location:
  • Phone: 662-253-1067
  • Fax: 662-253-1068
Mailing address:
  • Phone: 662-253-1067
  • Fax: 662-253-1068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number905458
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: