Provider Demographics
NPI:1346463791
Name:HENDERSON, TIFFNEY MARIE
Entity Type:Individual
Prefix:
First Name:TIFFNEY
Middle Name:MARIE
Last Name:HENDERSON
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 1:401 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45144-1412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 E 4TH ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:OH
Practice Address - Zip Code:45144-1412
Practice Address - Country:US
Practice Address - Phone:937-549-4137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications