Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LW0102X | Nurse Practitioner - Women's Health | 2017041087 | MO |
NPI | 1083120208 |
---|---|
Provider Name | Mrs. Tiffany Shanta Harold |
First Address | Fenton, MO 63026-2395 |
Second Address | Fenton, MO 63026-2395 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/12/2017 |
Last Update Date | 26/12/2017 |