MEDICARE: MS. TIFFANY HALLIBURTON

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	363LF0000X	Family Nurse Practitioner	R198341	MD

General Provider Information

NPI Number	:	1891165346
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TIFFANY HALLIBURTON

Provider Business Mailing Address
First Line	:	9601 PULASKI PARK DR
Second Line	:	SUITE 416
City	:	MIDDLE RIVER
State	:	MD
Zip	:	21220-1409
Country	:	US
Telephone Number	:	410-933-5678
Fax Number	:	410-933-1823

Provider Business Practice Location Address
First Line	:	7503B ANNAPOLIS RD
Second Line	:
City	:	HYATTSVILLE
State	:	MD
Zip	:	20784-1701
Country	:	US
Telephone Number	:	240-296-1112
Fax Number	:	240-296-1097

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

Provider Enumeration Date	:	09/28/2015
Last Update Date	:	09/28/2015

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