Provider Demographics
NPI:1548508203
Name:CLARK, TIFFANY G (FNP-C)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:G
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:G
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP-C
Mailing Address - Street 1:260 SUNNYMEADE RD
Mailing Address - Street 2:
Mailing Address - City:RUSTBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24588-3276
Mailing Address - Country:US
Mailing Address - Phone:434-485-9405
Mailing Address - Fax:
Practice Address - Street 1:2215 LANDOVER PL
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2115
Practice Address - Country:US
Practice Address - Phone:434-947-3944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-30
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024170609363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1548508203Medicaid
VA1548508203Medicaid