Provider Demographics
NPI:1558850743
Name:EDWARDS, TIFFANY
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:EDWARDS
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 1:470 E 3RD ST STE C
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-1630
Mailing Address - Country:US
Mailing Address - Phone:213-620-5712
Mailing Address - Fax:
Practice Address - Street 1:1481 WINDSOR DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5416
Practice Address - Country:US
Practice Address - Phone:310-988-9240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA172V00000XMedicaid