=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184293888
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIFFANY GILLION DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2021
-----------------------------------------------------
Last Update Date | 10/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3117 DUKE ST
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22314-4518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-751-8800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6801 METEOR PL APT 100
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22150-4567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-404-3541
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 0102208890
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------