Healthcare Provider Details

I. General information

NPI: 1639095607
Provider Name (Legal Business Name): TIFFANY MAXFIELD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 HIGHLAND AVE SE STE 100
ROANOKE VA
24013-2218
US

IV. Provider business mailing address

71 ANTIETAM HILL RD
DALEVILLE VA
24083-3247
US

V. Phone/Fax

Practice location:
  • Phone: 540-982-8881
  • Fax:
Mailing address:
  • Phone: 540-816-0460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number1300452
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: