Provider Demographics
NPI:1235826413
Name:RIDER, TIFFANY MAY
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MAY
Last Name:RIDER
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 1:207 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ZEIGLER
Mailing Address - State:IL
Mailing Address - Zip Code:62999-1123
Mailing Address - Country:US
Mailing Address - Phone:618-559-1813
Mailing Address - Fax:
Practice Address - Street 1:2401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1188
Practice Address - Country:US
Practice Address - Phone:618-997-5311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043090575164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse