Provider Demographics
NPI:1467218057
Name:JOHNSON, TIFFANY N
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:N
Last Name:JOHNSON
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 1:204 VILLAGE CT
Mailing Address - Street 2:
Mailing Address - City:RUTHER GLEN
Mailing Address - State:VA
Mailing Address - Zip Code:22546-1519
Mailing Address - Country:US
Mailing Address - Phone:540-940-9745
Mailing Address - Fax:
Practice Address - Street 1:204 VILLAGE CT
Practice Address - Street 2:
Practice Address - City:RUTHER GLEN
Practice Address - State:VA
Practice Address - Zip Code:22546-1519
Practice Address - Country:US
Practice Address - Phone:540-594-1171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAA63462535172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver