Provider Demographics
NPI:1407585441
Name:TIFUH, SHALLOT
Entity Type:Individual
Prefix:
First Name:SHALLOT
Middle Name:
Last Name:TIFUH
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 1:2603 MUSKOGEE ST
Mailing Address - Street 2:
Mailing Address - City:ADELPHI
Mailing Address - State:MD
Mailing Address - Zip Code:20783-1426
Mailing Address - Country:US
Mailing Address - Phone:240-645-7096
Mailing Address - Fax:
Practice Address - Street 1:2603 MUSKOGEE ST
Practice Address - Street 2:
Practice Address - City:ADELPHI
Practice Address - State:MD
Practice Address - Zip Code:20783-1426
Practice Address - Country:US
Practice Address - Phone:240-645-7096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDCNA20221230374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide