Healthcare Provider Details

I. General information

NPI: 1285918342
Provider Name (Legal Business Name): TIFFANY MOORE BRASSARD RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2011
Last Update Date: 10/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 JABARRAH AVE
SEYMOUR JOHNSON A F B NC
27531-2310
US

IV. Provider business mailing address

1050 JABARRAH AVE
SEYMOUR JOHNSON A F B NC
27531-2310
US

V. Phone/Fax

Practice location:
  • Phone: 919-722-1822
  • Fax: 919-722-1952
Mailing address:
  • Phone: 919-722-1822
  • Fax: 919-722-1952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL003702
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: