Healthcare Provider Details

I. General information

NPI: 1699769638
Provider Name (Legal Business Name): TINA MEDLEY PROFFIT AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 02/09/2025
Certification Date: 02/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8052 CARROLLTON PIKE
GALAX VA
24333-6087
US

IV. Provider business mailing address

8052 CARROLLTON PIKE
GALAX VA
24333-6087
US

V. Phone/Fax

Practice location:
  • Phone: 276-236-0778
  • Fax: 276-236-8600
Mailing address:
  • Phone: 276-236-0778
  • Fax: 276-236-8600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number6346
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number2201001359
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberNC1129
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number2101001685
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: