Provider Demographics
NPI:1417618356
Name:WILSON, TIFFANI A
Entity Type:Individual
Prefix:
First Name:TIFFANI
Middle Name:A
Last Name:WILSON
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 1:9411 HANNAHS MILL DR APT 304
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-6858
Mailing Address - Country:US
Mailing Address - Phone:443-468-1816
Mailing Address - Fax:301-979-7638
Practice Address - Street 1:3234 BELAIR RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21213-1228
Practice Address - Country:US
Practice Address - Phone:301-979-7501
Practice Address - Fax:301-979-7638
Is Sole Proprietor?:No
Enumeration Date:2022-01-03
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker