Provider Demographics
NPI:1518453067
Name:MOORE, TIFFANY M
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:M
Last Name:MOORE
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 1:4468 E 131ST ST
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44105-6972
Mailing Address - Country:US
Mailing Address - Phone:216-217-0555
Mailing Address - Fax:
Practice Address - Street 1:2490 LEE BLVD STE 103
Practice Address - Street 2:
Practice Address - City:CLEVELAND HTS
Practice Address - State:OH
Practice Address - Zip Code:44118-1255
Practice Address - Country:US
Practice Address - Phone:216-600-5194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker