Provider Demographics
NPI:1083049118
Name:JOHNSON, TIFFANY
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:JOHNSON
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 1:249 THOMAS S BOYLAND ST
Mailing Address - Street 2:APT 22C
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11233-4156
Mailing Address - Country:US
Mailing Address - Phone:347-395-9031
Mailing Address - Fax:
Practice Address - Street 1:993 E 39TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-3507
Practice Address - Country:US
Practice Address - Phone:347-395-9031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY823448171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor