Provider Demographics
NPI:1265871024
Name:SALVESON, TIFFANY ANN (IDC)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANN
Last Name:SALVESON
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6137 RAINTREE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-2050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:938 PATROL RD
Practice Address - Street 2:BLDG 938
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212
Practice Address - Country:US
Practice Address - Phone:904-542-5607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-14
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman