Provider Demographics
NPI:1326311234
Name:KELLEMS, TIFFANY LILLIAN (CDA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LILLIAN
Last Name:KELLEMS
Suffix:
Gender:F
Credentials:CDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 AGNOS RD
Mailing Address - Street 2:
Mailing Address - City:ASH FLAT
Mailing Address - State:AR
Mailing Address - Zip Code:72513-9778
Mailing Address - Country:US
Mailing Address - Phone:870-994-3103
Mailing Address - Fax:
Practice Address - Street 1:47 AGNOS RD
Practice Address - Street 2:
Practice Address - City:ASH FLAT
Practice Address - State:AR
Practice Address - Zip Code:72513-9778
Practice Address - Country:US
Practice Address - Phone:870-994-3103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist