MEDICARE: TIFFANY MASTIN REGISTERED NURSE

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	163WC1600X	Continuing Education/Staff Development Registered Nurse	RN289185	GA
2	163WH0200X	Home Health Registered Nurse	RN289185	GA
3	163WI0500X	Infusion Therapy Registered Nurse	RN289185	GA
4	163WS0200X	School Registered Nurse	RN289185	GA
5	163WC1500X	Community Health Registered Nurse	RN289185	GA

General Provider Information

NPI Number	:	1699350835
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY MASTIN REGISTERED NURSE

Provider Business Mailing Address
First Line	:	110 ASHTONBROOK DR
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30252-6705
Country	:	US
Telephone Number	:	404-922-1985
Fax Number	:

Provider Business Practice Location Address
First Line	:	2274 SALEM RD SE STE 1061273
Second Line	:
City	:	CONYERS
State	:	GA
Zip	:	30013-2097
Country	:	US
Telephone Number	:	844-286-8232
Fax Number	:

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

Provider Enumeration Date	:	03/09/2021
Last Update Date	:	11/18/2021

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