Healthcare Provider Details

I. General information

NPI: 1326681313
Provider Name (Legal Business Name): TIFFANY FRANCES AYAME HUMPHRIES NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2019
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 EMPIRE CT
FREDERICKSBURG VA
22408-1949
US

IV. Provider business mailing address

2720 WILLIAMSBURG ST APT 301
ALEXANDRIA VA
22314-5825
US

V. Phone/Fax

Practice location:
  • Phone: 540-371-0079
  • Fax:
Mailing address:
  • Phone: 903-431-7868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024178176
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: