Healthcare Provider Details

I. General information

NPI: 1386291896
Provider Name (Legal Business Name): TIFFANY BENNETT DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIFFANY WOODARD

II. Dates (important events)

Enumeration Date: 08/20/2019
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 W BADDOUR PKWY STE 120
LEBANON TN
37087-1510
US

IV. Provider business mailing address

PO BOX 306393
NASHVILLE TN
37230-6393
US

V. Phone/Fax

Practice location:
  • Phone: 615-443-9036
  • Fax: 615-443-9037
Mailing address:
  • Phone: 615-373-1350
  • Fax: 615-373-7116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12347
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: