MEDICARE: MARANDA S TIFFANY MPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT22240	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Y04EA	OTHER	FL	BCBS NON-PAR
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275725319
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARANDA S TIFFANY MPT

Provider Business Mailing Address
First Line	:	2 WOODFORD LN
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32164-7927
Country	:	US
Telephone Number	:	386-597-5869
Fax Number	:

Provider Business Practice Location Address
First Line	:	26 N BEACH ST
Second Line	:	SUITE B
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-5663
Country	:	US
Telephone Number	:	386-673-0201
Fax Number	:	386-677-8143

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2007
Last Update Date	:	01/20/2011

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Directions to “ MARANDA S TIFFANY MPT” Practice Location

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