Healthcare Provider Details

I. General information

NPI: 1336194877
Provider Name (Legal Business Name): TIFFANY E BOULD FNP-C,APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4250 CONGRESS ST STE 900
CHARLOTTE NC
28209-0044
US

IV. Provider business mailing address

1293 ELDRIDGE PKWY
HOUSTON TX
77077-1670
US

V. Phone/Fax

Practice location:
  • Phone: 980-299-5644
  • Fax:
Mailing address:
  • Phone: 832-486-1484
  • Fax: 832-486-5710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP126895
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License Number5015144
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5015144
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: