Provider Demographics
NPI:1356004816
Name:RUFFIN, TIERRA (SUDPT)
Entity Type:Individual
Prefix:
First Name:TIERRA
Middle Name:
Last Name:RUFFIN
Suffix:
Gender:F
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15723 40TH AVE W APT E201
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98087-1463
Mailing Address - Country:US
Mailing Address - Phone:850-207-0980
Mailing Address - Fax:
Practice Address - Street 1:9930 EVERGREEN WAY STE Z150
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-3889
Practice Address - Country:US
Practice Address - Phone:425-347-5121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61212506390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program