Healthcare Provider Details

I. General information

NPI: 1255939591
Provider Name (Legal Business Name): TIFFANIE NOLTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2020
Last Update Date: 10/09/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 HIGH ST
FARMVILLE VA
23909-1800
US

IV. Provider business mailing address

62 BUFFALO DR
HAMPTON VA
23664-1856
US

V. Phone/Fax

Practice location:
  • Phone: 757-236-0502
  • Fax:
Mailing address:
  • Phone: 757-236-0502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: