Provider Demographics
NPI:1548492267
Name:MOSBY, TIFFANY CHARON (LPN)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:CHARON
Last Name:MOSBY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MOUNDS
Mailing Address - State:IL
Mailing Address - Zip Code:62964-1344
Mailing Address - Country:US
Mailing Address - Phone:757-234-1923
Mailing Address - Fax:
Practice Address - Street 1:508 FULTON STREET
Practice Address - Street 2:DURHAM VA MEDICAL CENTER
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27700
Practice Address - Country:US
Practice Address - Phone:919-416-8001
Practice Address - Fax:919-286-6875
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-13
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002075837164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse