Provider Demographics
NPI:1710717525
Name:GILLIAM, TIFFANY (DACM, BCND, MAC, YS)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:DACM, BCND, MAC, YS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 WATER LILLY LOOP
Mailing Address - Street 2:
Mailing Address - City:EDENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27932-9283
Mailing Address - Country:US
Mailing Address - Phone:252-484-9165
Mailing Address - Fax:
Practice Address - Street 1:135 WATER LILLY LOOP
Practice Address - Street 2:
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932-9283
Practice Address - Country:US
Practice Address - Phone:252-484-9165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLEHP828175F00000X, 171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171400000XOther Service ProvidersHealth & Wellness CoachGroup - Single Specialty
No175F00000XOther Service ProvidersNaturopath