Provider Demographics
NPI:1508156712
Name:HERBERT, TIFFANY MICHELLE (CSA)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:MICHELLE
Last Name:HERBERT
Suffix:
Gender:F
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 PLANTERS GROVE TRL
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:TN
Mailing Address - Zip Code:38011-7068
Mailing Address - Country:US
Mailing Address - Phone:901-488-6406
Mailing Address - Fax:
Practice Address - Street 1:6027 WALNUT GROVE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2145
Practice Address - Country:US
Practice Address - Phone:901-761-1181
Practice Address - Fax:901-761-0589
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-10
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3644246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant