Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | 5015556 | NC |
N | 207PE0004X | Emergency Medical Services | 287174 | NC |
NPI | 1144980418 |
---|---|
Provider Name | Mrs. Tiffany Keller |
First Address | Winston Salem, NC 27103-3013 |
Second Address | Winston Salem, NC 27103-3013 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/12/2021 |
Last Update Date | 03/01/2022 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000 | N/A (01) |