Provider Demographics
NPI:1073380564
Name:CLARKE, TIFFANY ANN AUSTIN
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANN AUSTIN
Last Name:CLARKE
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 1:1666 S GRANT ST APT 6
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-2633
Mailing Address - Country:US
Mailing Address - Phone:707-501-3123
Mailing Address - Fax:
Practice Address - Street 1:1666 S GRANT ST APT 6
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-2633
Practice Address - Country:US
Practice Address - Phone:707-501-3123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHHKMY66X374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Single Specialty