Provider Demographics
NPI:1306191291
Name:ROUSE, TIFFANI ALISE
Entity Type:Individual
Prefix:
First Name:TIFFANI
Middle Name:ALISE
Last Name:ROUSE
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 1:17 ARGYLE ST
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-4805
Mailing Address - Country:US
Mailing Address - Phone:857-312-6950
Mailing Address - Fax:
Practice Address - Street 1:17 ARGYLE ST
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-4805
Practice Address - Country:US
Practice Address - Phone:857-312-6950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN87546164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse