Provider Demographics
NPI:1609021823
Name:TATE, TIFFANY JEAN (MED)
Entity Type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:JEAN
Last Name:TATE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2245 COYOTE LOOP
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:WY
Mailing Address - Zip Code:83014-9668
Mailing Address - Country:US
Mailing Address - Phone:307-690-6189
Mailing Address - Fax:
Practice Address - Street 1:2245 COYOTE LOOP
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:WY
Practice Address - Zip Code:83014-9668
Practice Address - Country:US
Practice Address - Phone:307-690-6189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY385H00000X385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care