Provider Demographics
NPI:1235657057
Name:SUTPHEN, TIFFANY DANIELLE
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DANIELLE
Last Name:SUTPHEN
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 1:1156 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112
Mailing Address - Country:US
Mailing Address - Phone:408-775-8768
Mailing Address - Fax:
Practice Address - Street 1:1156 N 4TH ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-4900
Practice Address - Country:US
Practice Address - Phone:408-775-8768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker