Provider Demographics
NPI:1366758138
Name:RAINEY, TIFFANY RENEE (NP-C)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:RENEE
Last Name:RAINEY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:RENEE
Other - Last Name:WHEELER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:106 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-7463
Mailing Address - Country:US
Mailing Address - Phone:678-635-8130
Mailing Address - Fax:678-635-8131
Practice Address - Street 1:2151 W SPRING ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-3115
Practice Address - Country:US
Practice Address - Phone:770-267-1828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAF0710420363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003105882AMedicaid