=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861947376
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIFFANY LEWALLEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2016
-----------------------------------------------------
Last Update Date | 08/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15476B DEDEAUX RD
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39503-2637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-539-3232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 251 JOHNSTON ST SE SUITE 300
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35601-2515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------