Provider Demographics
NPI:1093848947
Name:HUMPHREY, TIFFANY DIANE
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:DIANE
Last Name:HUMPHREY
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 1:1149 MAGNOLIA AVE APT 14
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4378
Mailing Address - Country:US
Mailing Address - Phone:310-769-5797
Mailing Address - Fax:
Practice Address - Street 1:3300 MOTOR AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-3712
Practice Address - Country:US
Practice Address - Phone:310-836-1223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner