Provider Demographics
NPI:1417456617
Name:DRAKE, TIFFANY (RN, CCM)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:DRAKE
Suffix:
Gender:F
Credentials:RN, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2107
Mailing Address - Street 2:
Mailing Address - City:POTTSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:75076-6988
Mailing Address - Country:US
Mailing Address - Phone:903-624-4529
Mailing Address - Fax:903-582-7281
Practice Address - Street 1:644 PEARCE DR
Practice Address - Street 2:
Practice Address - City:POTTSBORO
Practice Address - State:TX
Practice Address - Zip Code:75076-6988
Practice Address - Country:US
Practice Address - Phone:903-624-4529
Practice Address - Fax:903-582-7281
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-03
Last Update Date:2021-06-08
Deactivation Date:2021-04-26
Deactivation Code:
Reactivation Date:2021-06-08
Provider Licenses
StateLicense IDTaxonomies
TX652003163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse