Provider Demographics
NPI:1326636507
Name:CHEATHAM, TIFFANY RENEE (RN)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:RENEE
Last Name:CHEATHAM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 WHIRLAWAY RD
Mailing Address - Street 2:
Mailing Address - City:GRANITEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29829-3967
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6100 WHIRLAWAY RD
Practice Address - Street 2:
Practice Address - City:GRANITEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29829-3967
Practice Address - Country:US
Practice Address - Phone:803-293-8969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRN238298163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000OtherNA