Provider Demographics
NPI:1417604372
Name:SULLIVAN, TIFFANY LYNN
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LYNN
Last Name:SULLIVAN
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 1:5607 MIRADA DR
Mailing Address - Street 2:
Mailing Address - City:HOLIDAY
Mailing Address - State:FL
Mailing Address - Zip Code:34690-2227
Mailing Address - Country:US
Mailing Address - Phone:352-488-8240
Mailing Address - Fax:
Practice Address - Street 1:5607 MIRADA DR
Practice Address - Street 2:
Practice Address - City:HOLIDAY
Practice Address - State:FL
Practice Address - Zip Code:34690-2227
Practice Address - Country:US
Practice Address - Phone:352-488-8240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA303677251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health