Provider Demographics
NPI:1235508797
Name:DAVAULT, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:DAVAULT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:PALMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:112 PEARSON
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-4436
Mailing Address - Country:US
Mailing Address - Phone:501-847-1559
Mailing Address - Fax:501-847-3692
Practice Address - Street 1:112 PEARSON
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-4436
Practice Address - Country:US
Practice Address - Phone:501-847-1559
Practice Address - Fax:501-847-3692
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator