Basic Information
| Provider Information | |||||||||
| NPI: | 1518975945 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIPTON | ||||||||
| FirstName: | AUNDREA | ||||||||
| MiddleName: | JILL | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 JACKSON PIKE | ||||||||
| Address2: | |||||||||
| City: | GALLIPOLIS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456311560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404465371 | ||||||||
| FaxNumber: | 7404465711 | ||||||||
| Practice Location | |||||||||
| Address1: | 280 PATTONSVILLE ROAD | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403958805 | ||||||||
| FaxNumber: | 7403958855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 12/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 57516 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 299137 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2503606 | 01 | OH | MOLINA MEDICAID | OTHER | 2503606 | 05 | OH | MEDICAID | 310917085080 | 01 | OH | OH MEDICAID CARESOURCE | OTHER | 001714158 | 01 | MOUNTAIN STATE BCBS | OTHER | 7103239000 | 05 | WV | MEDICAID | P00122714 | 01 | RR MEDICARE | OTHER | 000000204789 | 01 | OH | UNISON MEDICAID | OTHER | 000000342883 | 01 | ANTHEM BCBS | OTHER |