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General NPI Number Information
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NPI Number | 1467971325
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Entity Type | Individual
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Provider Name | TIFFANY GRAY MOON WHNP-BC
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Gender | Female
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Dates
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Enumeration Date | 09/12/2017
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Last Update Date | 05/11/2020
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Provider Practice Location Address
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Address Line | 198 NC HIGHWAY 45 N
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City | PLYMOUTH
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State | NC
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Zip | 27962-9232
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Country | US
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Telephone | 252-791-3119
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Fax |
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Provider Business Mailing Address
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Address Line | 201 LEIGH ST
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City | EDENTON
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State | NC
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Zip | 27932-1657
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Country | US
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Telephone | 252-562-4410
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LW0102X
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Taxonomy Name | Women's Health Nurse Practitioner
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License Number | 5009694
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License Number State | NC
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