Basic Information
| Provider Information | |||||||||
| NPI: | 1477668556 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PATTERSON | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MOT, OTRL | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | HARRA | ||||||||
| OtherFirstName: | TIFFANY | ||||||||
| OtherMiddleName: | P | ||||||||
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| OtherCredential: | MOT, OTRL | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 40767 | ||||||||
| Address2: | CREDENTIALING DEPARTMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322030767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043763707 | ||||||||
| FaxNumber: | 9043915807 | ||||||||
| Practice Location | |||||||||
| Address1: | 14985 OLD SAINT AUGUSTINE RD UNIT 106 | ||||||||
| Address2: | CREDENTIALING DEPARTMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322589478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042889491 | ||||||||
| FaxNumber: | 9042889698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 02/04/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT10452 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | P00672041 | 01 | FL | RR MEDICARE | OTHER |