Provider Demographics
NPI:1376969790
Name:FABRICIUS, TIFFANY
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:FABRICIUS
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 1:937 E MARIPOSA ST APT 1A
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-2055
Mailing Address - Country:US
Mailing Address - Phone:626-318-5833
Mailing Address - Fax:
Practice Address - Street 1:2500 WILSHIRE BLVD STE 500
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-4310
Practice Address - Country:US
Practice Address - Phone:213-639-2665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-10
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator