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General NPI Number Information
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NPI Number | 1487517405
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Entity Type | Individual
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Provider Name | TIFFANY NICOLE KOTLARZ
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Gender | Female
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Dates
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Enumeration Date | 12/05/2025
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Last Update Date | 12/05/2025
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Provider Practice Location Address
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Address Line | 261 NORTH ST
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City | BRISTOL
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State | VA
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Zip | 24201-3275
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Country | US
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Telephone | 423-797-8532
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Fax |
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Provider Business Mailing Address
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Address Line | 1401 UNIVERSITY BLVD APT B8
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City | KINGSPORT
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State | TN
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Zip | 37660-8462
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Country | US
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Telephone | 423-440-6554
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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 | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number | 0735001449
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License Number State | VA
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