Basic Information
| Provider Information | |||||||||
| NPI: | 1720441355 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEITH | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | EDWARDS | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MHS, PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EDWARDS | ||||||||
| OtherFirstName: | TIFFANY | ||||||||
| OtherMiddleName: | BROOKE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 247 | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394410247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013996169 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1220 JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394404355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014264000 | ||||||||
| FaxNumber: | 6014264105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2016 | ||||||||
| LastUpdateDate: | 11/05/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | MA058228 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | PA00374 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.