Provider Demographics
NPI:1407218266
Name:TIFANG, FON ELVIS
Entity Type:Individual
Prefix:
First Name:FON
Middle Name:ELVIS
Last Name:TIFANG
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:FON
Other - Middle Name:ELVIS
Other - Last Name:TIFANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:15524 FINCHINGFIELD WAY
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-8091
Mailing Address - Country:US
Mailing Address - Phone:240-360-9129
Mailing Address - Fax:
Practice Address - Street 1:15524 FINCHINGFIELD WAY
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-8091
Practice Address - Country:US
Practice Address - Phone:240-360-9129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA11914374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide