Provider Demographics
NPI:1578335279
Name:EAST, TIFFANY JEAN
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:JEAN
Last Name:EAST
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 1:3909 ORCHARD LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-4751
Mailing Address - Country:US
Mailing Address - Phone:502-345-7943
Mailing Address - Fax:
Practice Address - Street 1:3909 ORCHARD LAKE DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-4751
Practice Address - Country:US
Practice Address - Phone:502-345-7943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1103531163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse