Provider Demographics
NPI:1619592474
Name:WILSON, TIFFANY MICHELLE LADONNA
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MICHELLE LADONNA
Last Name:WILSON
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 1:3575 KEITH ST NW STE 205
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-4326
Mailing Address - Country:US
Mailing Address - Phone:423-559-0444
Mailing Address - Fax:
Practice Address - Street 1:3575 KEITH ST NW STE 205
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-4326
Practice Address - Country:US
Practice Address - Phone:423-559-0444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2255A2300X, 390200000X
2255A2300X
TN29662255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program