Healthcare Provider Details

I. General information

NPI: 1487517405
Provider Name (Legal Business Name): TIFFANY NICOLE KOTLARZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

261 NORTH ST
BRISTOL VA
24201-3275
US

IV. Provider business mailing address

1401 UNIVERSITY BLVD APT B8
KINGSPORT TN
37660-8462
US

V. Phone/Fax

Practice location:
  • Phone: 423-797-8532
  • Fax:
Mailing address:
  • Phone: 423-440-6554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number0735001449
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: