Provider Demographics
NPI:1063471795
Name:REECE, TIFFANY OPAL LIVENGOOD (PA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:OPAL LIVENGOOD
Last Name:REECE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 604050
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-4050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6329 UNITY ST STE A
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-7186
Practice Address - Country:US
Practice Address - Phone:336-793-2518
Practice Address - Fax:336-793-9589
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000102880363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1285682310OtherWSCA GRP NPI #
NC2752667AMedicare PIN
S93995Medicare UPIN