Provider Demographics
NPI:1558908251
Name:HARRIS, TIFENIE HIROKO
Entity Type:Individual
Prefix:
First Name:TIFENIE
Middle Name:HIROKO
Last Name:HARRIS
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 1:655 125TH AVE
Mailing Address - Street 2:
Mailing Address - City:MORLEY
Mailing Address - State:MI
Mailing Address - Zip Code:49336-9473
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8540 105TH AVE
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:MI
Practice Address - Zip Code:49346-9764
Practice Address - Country:US
Practice Address - Phone:231-972-2710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-02
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIF06191538207Q00000X
MI4704250274363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine