Healthcare Provider Details

I. General information

NPI: 1316336126
Provider Name (Legal Business Name): TIFFANY ELLIS KNIGHT LAT, ATC, OTC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2015
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 N COLLEGE RD
WILMINGTON NC
28405-8816
US

IV. Provider business mailing address

5570 LIVINGSTON CHAPEL RD
DELCO NC
28436-9626
US

V. Phone/Fax

Practice location:
  • Phone: 910-350-2089
  • Fax:
Mailing address:
  • Phone: 910-617-1094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberLAT-3629
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1575
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code246ZX2200X
TaxonomyOrthopedic Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: