Provider Demographics
NPI:1093584039
Name:DAUGHERTY, TIFFANY
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:DAUGHERTY
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 1:3026 LAKE CITY HWY
Mailing Address - Street 2:
Mailing Address - City:ROCKY TOP
Mailing Address - State:TN
Mailing Address - Zip Code:37769-5533
Mailing Address - Country:US
Mailing Address - Phone:865-246-8941
Mailing Address - Fax:
Practice Address - Street 1:3026 LAKE CITY HWY
Practice Address - Street 2:
Practice Address - City:ROCKY TOP
Practice Address - State:TN
Practice Address - Zip Code:37769-5533
Practice Address - Country:US
Practice Address - Phone:865-246-8941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-01
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN245722163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty