Provider Demographics
NPI:1003274424
Name:BOOLS, TIFFANY R
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:R
Last Name:BOOLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12447 3RD ST
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-4228
Mailing Address - Country:US
Mailing Address - Phone:909-747-7341
Mailing Address - Fax:
Practice Address - Street 1:12447 3RD ST
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-4228
Practice Address - Country:US
Practice Address - Phone:909-747-7341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 272711164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse