Basic Information
Provider Information | |||||||||
NPI: | 1306490115 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NORTHINGTON | ||||||||
FirstName: | EMMANUAL | ||||||||
MiddleName: | TIFFANY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN, FNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NORTHINGTON | ||||||||
OtherFirstName: | EMMANUAL | ||||||||
OtherMiddleName: | TIFFANY | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | EMMANUAL GEORGE RN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 15 COUNCIL MOORE RD | ||||||||
Address2: |   | ||||||||
City: | CRAWFORDVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 323273117 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8509267105 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 15 COUNCIL MOORE RD | ||||||||
Address2: |   | ||||||||
City: | CRAWFORDVILLE | ||||||||
State: | FL | ||||||||
PostalCode: | 323273117 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8509267105 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/30/2019 | ||||||||
LastUpdateDate: | 01/17/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/17/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 11004053 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | APRN11004053 | 01 | FL | STATE OF FLORIDA DEPARTMENT OF HEALTH | OTHER | RN9243894 | 01 | FL | STATE OF FLORIDA DEPARTMENT OF HEALTH | OTHER |