Healthcare Provider Details

I. General information

NPI: 1912249418
Provider Name (Legal Business Name): TIFFANY J LIBBY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2013
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 WAMPANOAG TRL STE 401
RIVERSIDE RI
02915-2237
US

IV. Provider business mailing address

15 LA SALLE SQ
PROVIDENCE RI
02903-1814
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-7959
  • Fax: 401-432-6997
Mailing address:
  • Phone: 401-444-6779
  • Fax: 401-444-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD16408
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: