Basic Information
| Provider Information | |||||||||
| NPI: | 1760678106 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | TIFFANI | ||||||||
| MiddleName: | MARIA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WHITE | ||||||||
| OtherFirstName: | TIFFANI | ||||||||
| OtherMiddleName: | MARIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 716 SPRING ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | WISE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763288910 | ||||||||
| FaxNumber: | 2763284318 | ||||||||
| Practice Location | |||||||||
| Address1: | 716 SPRING ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | WISE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763288910 | ||||||||
| FaxNumber: | 2763284318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2007 | ||||||||
| LastUpdateDate: | 02/22/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0102202126 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00739464 | 01 | RR MEDICARE | OTHER | 7100077080 | 05 | KY | MEDICAID | 1760678106 | 05 | VA | MEDICAID |