Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 4301105422 | MI |
Y | 2080A0000X | Adolescent Medicine | 4301105422 | MI |
NPI | 1073931184 |
---|---|
Provider Name | Tiffney Monique Widner |
First Address | Detroit, MI 48201 |
Second Address | Detroit, MI 48201-2119 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/04/2014 |
Last Update Date | 02/08/2017 |