Provider Demographics
NPI:1568725174
Name:JOHNSON, TIFFANY LYNN
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:LYNN
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 1:18 REYNOLDS RD
Mailing Address - Street 2:
Mailing Address - City:PEQUANNOCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07440-1707
Mailing Address - Country:US
Mailing Address - Phone:631-327-2547
Mailing Address - Fax:
Practice Address - Street 1:556 PASSAIC AVE
Practice Address - Street 2:
Practice Address - City:WEST CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-7449
Practice Address - Country:US
Practice Address - Phone:973-808-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015417363AM0700X
NJ25MP00317300363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical