Healthcare Provider Details

I. General information

NPI: 1720904014
Provider Name (Legal Business Name): TIFFANY EVE FASS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1880 N BROAD ST
FUQUAY VARINA NC
27526-3657
US

IV. Provider business mailing address

123 TEASER DR
FUQUAY VARINA NC
27526-4630
US

V. Phone/Fax

Practice location:
  • Phone: 919-557-8222
  • Fax: 919-557-8223
Mailing address:
  • Phone: 919-986-5710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: