Provider Demographics
NPI:1679754592
Name:GRAYBILL, TIFFANY NICOLE (DO)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICOLE
Last Name:GRAYBILL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1459 S HIGLEY RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-5046
Mailing Address - Country:US
Mailing Address - Phone:480-543-6790
Mailing Address - Fax:480-543-5925
Practice Address - Street 1:1459 S HIGLEY RD
Practice Address - Street 2:SUITE 106
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-5046
Practice Address - Country:US
Practice Address - Phone:480-543-6790
Practice Address - Fax:480-543-5925
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-050861207R00000X
WAOP60139757207R00000X
AZ005714207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ148509Medicare PIN
AZZ148779Medicare PIN