Healthcare Provider Details

I. General information

NPI: 1750293239
Provider Name (Legal Business Name): TIFFANY REGAN ANSELMO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 195
UNION MS
39365-0195
US

IV. Provider business mailing address

PO BOX 195
UNION MS
39365-0195
US

V. Phone/Fax

Practice location:
  • Phone: 601-504-5632
  • Fax:
Mailing address:
  • Phone: 601-504-5632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number908809
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: